Body sculpting consent form

BODY SCULPTING CONSENT FORM
Name

First Name Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Date of Birth

Month Day Year
Date
Gender

Male Female
I acknowledge that:

I understand that Body Sculpting benefits in terms of shaping the body with the use of infrared sauna, laser lipo, ultrasound cavitation, radiofrequency, vacuum therapy, or wood therapy. I understand that Body Sculpting may involve risk which includes, redness, swelling, irritation, skin reaction, or increased heart rate. I understand that Body Sculpting is not a treatment for any medical condition, nor used to relieve symptoms of any medical condition. I understand that Body Sculpting is not a treatment for overweight or obesity. It is likewise not recommended that persons with such conditions undergo this treatment. It has been explained to me that Body Sculpting shall not be applied across or on the thoracic cavity, over carotid sinus nerves, inflamed, infected, or swollen areas of the skin, nor near cancerous areas. I have been advised to take a low-fat diet and exercise in order for an effective Body Sculpting treatment. Before undergoing treatment, I have or provided my medical and health history, including any medications that I am currently taking or have taken in the past.
Further, I acknowledge that:

I understand that women during menstruation or with fever are not allowed to have treatment. As such, appointments can be rearranged on a later schedule. I understand that pregnant or intending to be pregnant are not allowed to undergo Body Contouring treatment.
By signing this form, I declare that I am of legal age and give my full consent to the Body Sculpting treatment. I have fully read and understand the contents provided herein and I assume the risks involved, including any complications and benefits resulting from the foregoing. I have had the opportunity to ask questions and clarifications and by which I have received answers to my satisfaction. I am executing this consent with full knowledge and responsibility to my actions.
Signature

Clear
Date Signed

Month Day Year
Date
Should be Empty:

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BODY SCULPTING CONSENT FORM