Ultrasonic Cavitation Consent Form

Name

First NameLast Name

Date of Birth

Date

Phone Number

Please enter a valid phone number.

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

YesNo

What type of allergies do you have?

YesNo

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

YesNo

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