Body Sculpting Consent Form

BODY SCULPTING CONSENT

SCULPTED BY TIFFANY
Thank you for your interest in having your body sculpting treatments with me. I am excited to be helping you with your desires to reach your goals for a better body that helps boost your confidence and bring a better lifestyle. I have provided some information that can help you achieve your best results:
1. Drink plenty of water before and after treatment
2. Have a 2-hour fast prior to treatment
3. Perform some physical activity such as exercise
4. Manage your food intake
5. Avoid alcoholic drinks and those with high sugar before and after treatment
If you'd like pre/post op information in depth, please visit the instagram page @sculptedbytiffany.

Please take note that results may vary for the treatment.

During the treatment, you might feel a warm discomfort. If it's not tolerable, please advise me.

At an average, you can expect a reduction from 0.5 inches to as much as 2.0 inches after a treatment.
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth*

MonthDayYear
Date
Age
Contact In Case Of Emergency
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Relationship*
Vacuum therapyWood TherapyUltrasonic CavitationRFLaser LipoBBL
AbdomenArmsButtocksCheeksChinLegsThighs

Medical History*

Rows	Yes	No
Are you pregnant or nursing?
Are you immunocompromised?
Do you have any liver or kidney disorders?
Do you have any thyroid gland dysfunction?
Do you have epilepsy?
Do you have cancer or a history of cancer?
Do you have photosensitivity to sun exposure?
Are you taking any drugs that may cause photosensitivity?
Have you undergone an organ transplant?
Do you have any current infections?
Do you have advanced untreated diabetes?
Do you have uncontrolled Hypertension?
Do you have any kind of heart condition?
Do you have hemophilia (blood clotting condition)?
Do you have a keloid scar?
Do you have any infectious disease or tuberculosis?
Do you have a pacemaker?
Do you have any open skin legions?

If you have answered 'Yes' to any of the medical conditions above, we advise you to see your doctor first before undergoing treatment with us. We reserve the right to not begin any treatment should we believe that such treatment may cause risk to our client due to the medical conditions which the client has.
Please make sure that there are no metal instruments that are present on or in your body during the scheduled treatments. If you have any heart or liver problems, uncontrolled high blood pressure, or cancer or undergoing radiology treatments, please see your doctor first. However, if you have a pacemaker, it is unfortunate that we cannot proeed with any of the services that we offer.
CONSENT

I hereby declare that I am of legal age and I understand that treatments for body sculpting do not guarantee absolute results. In order to achieve my desired results, I may be required to undergo several treatments with an appropriate diet and physical activity. I understand that non-invasive surgery procedures do not rid the body of visceral fat.

I hereby release and forever discharge Sculpted By Tiffany, its affiliates, partners, agents, and employees from any and all causes of action. I will hold harmless, Sculpted By Tiffany for any liabilities, damages, injuries whether seen or unforeseen.

I understand that any procedure under Sculpted By Tiffany does not constitute medical treatment or cure to any illness.

By signing this form, I declare that all information and declarations I have made above are true and correct to the best of my knowledge. I have had the opportunity to ask questions and which were answered to me and to my satisfaction. I have likewise read all the information above and give my consent with my full knowledge, understanding, and assumption to the risks involved in the treatment, without any coercion, inducement, or undue influence.

I understand that Body Contouring benefits in terms of shaping the body with the use of laser lipo, ultrasound cavitation, radiotrequency, vacuum therapy, or wood therapy

I understand that Body Contouring may involve risk which includes, redness, swelling, irritation, skin reaction, or increased heart rate.

I have been advised to take a low-fat diet and exercise in order for an ettective Body Contouring Treatment.
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BODY SCULPTING CONSENT