Ultrasonic Cavitation Consent Form

Name

First NameLast Name

Date of Birth

Date

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Which part of the body will undergo ultrasound cavitation treatment?

Do you have any allergies?

What type of allergies do you have?

Are you currently taking any medications?

If yes, what are the medications you're currently having?

Are you pregnant or breastfeeding?

Do you have any cardiovascular disease?

Do you have any Thyroid problems (IE hypo / hyperthyroidism)

Do you have a high blood pressure or hypertension?

Do you suffer from epilepsy?

Do you have any kind of cancer?

Did you undergo any surgery in the abdomen before?

Did you undergo any transplant?

Do you have any current infection?

Do you have any communicable disease?

I authorized ABC Clinic to perform this diagnostic procedure as part of my treatment.

I understand the complications and risks that might happen as a result of this procedure. However, I still like to proceed.

I release and hold harmless ABC Clinic against any claims, damages, costs, which may occur during or after the procedure.

I understand that I need to follow the pre-care and post-care instructions given by the clinic.

By signing this consent, I confirm that I have read and understood all the information indicated in this document. I also assure you that I'm of legal age. I fully accept all responsibilities for these or any other complications that may occur during the procedure.

Signature

Date Signed

Date

Ultrasonic Cavitation Consent Form

Consent Agreement