I have completed this form to the best of my ability and knowledge. I agree to inform the technician of any changes in the above information. I agree that I do not have any condition(s) that would make the requested treatment unsuitable. I will inform the technician of any discomfort I may experience at any time during my treatment to allow them to adjust accordingly. I agree to waive all liability toward my technician and the Forever Confidence for any injury or damages incurred due to any misrepresentation of my health.

Please read each of the statements below:

I certify I am over the age of 18.
I have voluntarily elected to receive body contouring after the nature and purpose of this treatment has been explained to me.
I understand that body contouring can be used to reduce fat deposits, but is not intended to be a weight loss solution.
I understand that the following conditions preclude me from having this treatment at this time and verify that none of the following conditions apply to me at this time:
• Cardiac issues
• Cancer
• Infected, inflamed, or swollen skin
• Metallic implant (pacemaker)
• Pregnant/Lactating

I recognize and understand that some clients experience more chance and improvement then others. In virtually all cases, multiple treatments are required
in order to realize a difference.

I understand and acknowledge that there are risks involved with the treatment I will be receiving including, but not limited to:
• Redness
• Swelling
• Irritation
• Skin reaction
• Increased heart rate

I have been informed of possible benefits, risks, and complications, and I have had the opportunity to ask questions regarding these risks and other
possible complications.

I have, to the best of my knowledge, given an accurate account of my medical history, including all known allergies or prescription drugs or products I am
currently ingesting or using topically. Given the above, I understand that response of treatment varies on an individual basis and specific results are NOT guaranteed. Therefore, in consideration for any treatment / service received, I agree to unconditionally defend and hold harmless and release Forever Confidence Aesthetics and the individual that provided my treatment from all liability, for any condition or result, known or unknown, that may arise as consequences of any treatment
/services that I received. Petitions, and causes of actions with I, my heirs, representatives, executors, or any other persons may make while acting on my
behalf or on behalf of my state.