BODY CONTOURING CONSENT FORM-Bella Silhouette Spa

Date

First Name

Last Name

Date of birth

Email

(Your email address will be used for appointment confirmations, and quarterly newsletters)

I want to subscribe to the mailing list.

Phone Number

Address

How did you hear about us?

Please specify area of treatment (body, face, etc)

Are you taking any medication or receiving any medical treatments?

Yes

No

If Yes, please specify and list below

Do you have any allergies?

Yes

No

Not sure

If Yes, please specify and list below

Do you have any (relevant) past medical history that I should know about? Please list below

Are you take recreational drugs?

Yes

No

If Yes, please specify and list below

What are your expectations for treatment/your goals for treatment?

Are you pregnant and/or breast feeding?

Yes

No

Do you plan on getting pregnant?

Yes

No

Please select if you suffer from any of the following conditions:

If you selected one or more, please provide details below

PURPOSE OF THE CONSENT:

To provide written information regarding the risks, benefits, and alternatives of the treatment this consent is written. It is important that the patient should fully understand the treatment priorly. Before signing the consent, the patient should ask any of the questions regarding the treatment.

THE 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, breast feeding, have a lymphatic disorder, acute illness, metal implants, pacemakers, or are currently being treated for active cancer.

I acknowledge and consent to the following:

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

Your Signature

*

Date

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.