Body Sculpting Consent Form

Thank you for your interest in having your body sculpting procedure with us. We are with you on your desire to reach your goals for a better body that helps boost your confidence and bring a better lifestyle. We have provided some information that can help you achieve your best results:

Drink plenty of water before and after treatment
Have a 2-hour fast prior to treatment
Perform some physical activity such as exercise
Manage your food intake
Avoid alcoholic drinks and those with high sugar before and after treatment

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 our technician.

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

Phone Number

Please enter a valid phone number.

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Gender

MaleFemale

Marital Status

SingleMarriedWidowedDivorced

Date of Birth

Date

Age

Contact In Case Of Emergency

Name

First NameLast Name

Phone Number

Please enter a valid phone number.

Relationship

Treatment

Cellulite reductionUltrasonic CavitationNon-surgical lipo

Areas to be treated

Medical History

	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?

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.

Reminder:

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 the Clinic, its affiliates, partners, agents, and employees from any and all causes of action. I will hold harmless, the Clinic for any liabilities, damages, injuries whether seen or unforeseen.

I understand that any procedure under the Clinic 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.

Signature

Date

My Products

Ultimate Full Body TreatmentSelect 3 target areas for treatment, 2 hour session, complimantary red light face treatment.

$190.00 Quantity

Abdominal TreatmentFat and Cellulite reduction treatment using high frequency cavitation

$85.00 Quantity

Arm SlimmingCavitation and firming treatment of the arms

$55.00 Quantity

Body WrapGreat for workout sessions, work, or basic tasks of 20+ minutes of continuous movement. Specialized slimming cream and body wrap activated the sweat glands before your work out even begins!

$18.00 Quantity

Chin/NeckFirming and fat reduction

$55.00 Quantity

Thigh SlimmingTreatment of inner and outer thighs. Fat/cellulite reduction

$70.00 Quantity

Booty EnhancementNon invasive lifting and firming of the buttocks using a combination of cavitaion, vacum therapy and RF.

$110.00 Quantity

Total

$0.00

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