• Client Intake & Medical History

    FAT DISSOLVING TREATMENT
  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • What are your area's of concern for treatment?*
  • Have you ever received a fat dissolving treatment before?*
  • Have you had any recent cosmetic treatments/procedures within the last 3 months?*
  • Are you currently taking any blood thinning medication?*
  • Do you have issues with fluctuating weight?*
  • Have you taken Isotretinoin medication within the last 6 months?*
  • Do you smoke?*
  • Do you drink alcohol on a regular basis?*
  • Are you currently..?*

  • Medical History

    Please check all that apply
  • Have you ever had an allergic reaction to any of the following?*
  • Check the conditions that apply*

  • Consent and Liability Wavier

    Initial each section.

  • Hyaluron Fat Dissolve Treatment (also known as Injection Lipolysis) remove subcutaneous fat by targeting localized areas of fat not amenable to diet and exercise. Using a synthetic form of deoxycholic acid, fat cells are broken down and flushed out of the body via the lymphatic system. Many areas of the body can be treated, including double chin, abdomen, flanks, inner/outer thighs, back and under arms. Typically, several treatments are required for optimal results.

    Please read and initial the following statements:

  • I voluntarily elect to receive Hyaluron Fat Dissolve Treatments and have had all risks and hazards involved, fully explained to me by Body Adore*
  • I understand that this treatment can eliminate small pockets of localized fat, shape areas of the body and boost skin elasticity. However, I understand that it is not intended as a weight loss solution.*
  • I understand that after the procedure I may experience redness, swelling, bruising, pain, tingling, itching, nodules, sensitivity to pressure and/or excessive warmth. These symptoms are common and should resolve within a week, but can last for up to a month.*
  • I understand that several treatments will be required to reach the desired results and a treatment plan has been discussed with my Technician.*
  • I understand that it can take 4-6 weeks for the body to absorb and flush out the fat cells and can take several weeks before results become visible*
  • I understand that the use of compression garments and chin straps are highly recommended after treatment on certain areas of the body to reduce swelling and bruising and to enhance results. Please note - these need to be tailored to your size and our staff will discuss with you from where to purchase.*
  • I understand that no guarantee can be given regarding final results, and that unsatisfactory results may includestubborn fat, asymmetry or loose skin following treatment.*
  • I have read and understood the post-treatment home care instructions and understand how important it is to follow all instructions given to me for post-treatment care. In the event I may have additional questions or concerns regarding my treatment or post-treatment care, I will consult Body Adore immediately.*
  • The information I have provided about my medical history is accurate to the best of my knowledge, including all known allergies and/or prescription drugs/products I am currently ingesting or using topically.*
  • I hereby give my informed consent to receive Hyaluron Fat Dissolve Treatment. I have read and fully understand this agreement and all information detailed above. This agreement will remain in effect for this and all subsequent Hyaluron Fat Dissolve Treatment conducted by Body Adore.*
  • Should be Empty: