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Have you been diagnosed with any of the following conditions? Please select all that apply or select "none of the above".
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PURPOSE OF CONSENT:
To provide written information regarding the risks, benefits, and alternatives of the treatment. It is important that the patient fully understands the treatment and it's process prior to moving forward with the treatment. Before signing the consent, the patient should ask any of the questions regarding the treatment.
TREATMENT INFORMATION:
Nonsurgical body contouring is also known as nonsurgical fat reduction. There are a variety of nonsurgical fat reduction procedures. These procedures reduce or remove stubborn pockets of fat to contour and shape different areas of the body. Most nonsurgical fat reduction treatments are based on one of these four principles:
-Cryolipolysis, or controlled cooling, uses freezing temperatures to target and destroy fat cells.
-Laser lipolysis uses controlled heating and laser energy to target fat cells.
-Radiofrequency lipolysis uses controlled heating and ultrasound technology to target fat cells.
-Injection lipolysis uses injectable deoxycholic acid to target fat cells.
Nonsurgical body contouring procedures aren't intended to be weight loss solutions. Ideal candidates are close to their desired weight and want to eliminate stubborn pockets of fat that are resistant to diet and exercise. With most body contouring procedures, your body mass index shouldn't be over 30.
PRECAUTIONS:
Body sculpting treatments are not recommended if you are pregnant, breastfeeding, have a lymphatic disorder, acute illness, metal implants, pacemakers, or are currently being treated for active cancer.
I acknowledge that:
(By checking the box next to each statement below you are acknowledging that you understand and agree to that statement.)
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I understand that body contouring can have certain side effects such as skin removal, redness, swelling, tenderness, cardiac issues etc.
I understand that body contouring does not treat medical conditions nor does it claim or guarantee to treat or relieve any medical condition.
I give permission to my therapist to perform the procedure we have discussed and will hold her and her staff harmless from any liability that may result from this treatment.
I have read and understand the post-treatment home care instructions. I am willing to follow recommendations made by my esthetician for a home care regimen that can minimize or eliminate possible negative reactions.
I understand that in the event I have questions or concerns regarding my treatment, I will consult the esthetician immediately.
Refund & Re-Schedule Policy:
(By checking the box next to each statement below you are acknowledging that you understand and agree to that statement.)
All packages are non-refundable.
There are no refunds for missed or cancelled sessions.
Cancelled appointments CAN be re-scheduled.
No shows CAN NOT be rescheduled.
By signing this form, I declare that I am of legal age and give my full consent to the Body Contouring treatment. I have fully read and understand the contents provided herein and I assume the risks involved, including any complications and benefits resulting from the foregoing. I have had the opportunity to ask questions and clarifications and by which I have received answers to my satisfaction. I am executing this consent with full knowledge and responsibility to my actions.
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