Body Contouring By JLsugar.me

Body Contouring By JLsugar.me

Client Waiver & Intake Form
Client Name*

First NameLast Name
Date of birth*

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Date
Phone Number*
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Email*
example@example.com
Consent For Use Of Lipolysis, Cavitation, Radio Frequency & Ultrasound

Lipo-Laser is one of the tools that we can use to help you reach your goals and target specific areas of your body. Once the fat cell is broken down, the lymphatic system transports the free fatty acids and glycerol to the liver for processing to be used as an energy source for your body. It is critical that the dietary and lifestyle changes are made to help support the goals of treatment.

A reduced calorie diet and an exercise program that will help burn 350-500 calories post treatment are ideal. Individual results may vary and it is the responsibility of the client to ensure they are doing appropriate healthy lifestyle changes to ensure maximum results. Chiropractic adjustments are required to help stimulate and support lymphatic drainage to clear the free fatty acids and glycerol from your system. Supplements may be provided to block the absorption of free fatty acids and glycerol by the cells prior to either being used as an energy source or excerted out the urinary tract. Most clients report 1/2 inch reduction with each treatment and multiple inches can be lost with a series of treatments.
I Confirm The Following*

I am over 18I am NOT pregnant or LactatingI do NOT have EpilepsyI do NOT have a life sustaining artificial lung/heartI have no known liver or kidney disordersI have no known thyroid gland dysfunctionsI have no known photosensitive or sun exposureI do not have cancer or a history of cancerI do not have uncontrolled hypertensionI do not have a comprimised immune systemI am not trying to get pregnant within 3 months (no possible pregnancy at the moment of my treatment)
Limitation to Treatment*

I understand that there are no gaurantees as to the results of this treatmentI understand there are no refunds for this treatmentI understand that to achieve maximum results, I may require several treatmentsTo acheive maximum results, I understand diet and consistency will assist to sustain and create accumulative degree of overall spot fat reduction and body contouringI understand that every body is different and my body may not have the same results as others
RISK:

I have been informed and I understand that temproary hyperpigmenation/hypopigmenation, or a minor burn(on rare occasions) may occur as a result of the treatment. We make every effort to avoid these contraindications. However, it may happen which could cause a delay in treatment in that specific area. I hererby certify that all the information that I have provided has been accurate and truthful.
I hearby authorize Jeddahlyn Laurin to perform lipolysis procedures for the purpose of aesthetic body contouring*
Initials
ENSURE YOUR BEST RESULTS
- Do not eat 2-4 hours prior to treatment(s)
- Drink plenty of water before and after every treatment
- Consume at least 8-10 glasses of water daily while undergoing Lipo-Laser treatment(s)
- Perform 30-minutes of cardio-exercise after every treatment
- Manage caloric intake during treatment (excess calories will counteract the laser treatments)
- Abstain from alcohol beverages before and after treatment(s)
- Abstain from caffeine before and after treatment(s)
Cancellation & Deposit Policy - A deposit of $85 is required at the time of booking. 48hr cancellation notice or else deposit is lost.
Initials
My signature herein constitutes my acknowledgement that I am a competent consenting adult of at least 18 years of age and further I,*

Have read and understand the information provided in this formHave received all the informtaion I desire concerning my procedureUnderstand all post treatment/aftercare reccomendations and agree to adhere to themConsents to take photographs of treatment for the purpose of progress pictures & social mediaFreely assume any risks of complications or injury from known or unknown causes associated with, relating to, or otherwise arising out of this procedure
Iblanks* consent to, and authorize Jeddahlyn Laurin to perform the laser treatment(s) for the area ofblank* .
Signature*

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