Multilase Lipo+ Plus  Client Consent Form  Logo
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  • Personal Details

  • Medical History

  • This form must be completed and guidance notes followed before commencing treatment.

    If you answer YES to any CONTRAINDICCATIONS, you CANNOT receive treatment.

    If you answer YES to any CAUTIONS, you must seek MEDICAL APPROVAL for treatment to occur.

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  • Lifestyle Habits

  • Terms, Conditions, Indemnity

  • I understand that while non-invasive photobiomodulation (PBM) phototherapy laser lipolysis is a low risk procdeure, I understand and acknowledge certain risks and side effects are possible, including but not limited to redness, swelling, bruising, or minor skin irritation. I have had the opportunity to discuss these risks and ask any questions concerning the treatment.

    I have been fully informed about non-invasive PBM Phototherapy and what the expected outcomes may be and I understand no guarantee can be given as to the final result obtained. I am aware that results may vary depending upon my medical history, compliance to recommended instructions and each individual's response and I am also aware of the importance of diet and exercise in conjunction with this therapy. I understand that it is my responsibility to inform the clinician of any changes to my medical history.

    I understand the I may require a series of PBM therapy sessions and that regular ongoing PBM therapy may be needed, and that best results are achieved by exercising within 6 hours of my treatment. I also acknowledge any action taken to enhance lymphatic drainage, either via dry brushing or lymphatic massage, will assist my results.

    I am aware that I am required to pay for the PBM therapy according to the agreed fee structure, unless stated otherwise in writing.

    Appointment Cancellation requires 24 hour notice.

    I hereby release Yates Total Health, its employees and agents from any and all liability, claims, or damages that may arise in my participation in non-invasive PBM phototherapy laser lipolysis. I understand this waiver applies to the Initial and all subsequent treatments I may receive as outlined.

  • Photo Consent

  • Signature of Consent

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