Beyond Body Sculpting Waiver-BeyondBodySculpting

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In this waiver, you will be required to read and understand a body sculpting session in order to maximize your results. In addition, you will find listed a variety of conditions that we prefer to know upfront.

Should you get to a condition that prohibits you from finishing the waiver, please call us at 636-875-7150.

Please initial below acknowledging you will carefully read the details and verify any listed pre-existing conditions.

TERMS and CONSIDERATIONS

I hereby authorize and its designated providers to treat me with the Ultimate Contour device. I understand that this is a non-invasive procedure that is intended to change the appearance of the treatment area by using ultrasound and/or radio frequency (RF) energy to provide ultrasound lipolysis and uniform deep tissue heating for skin tightening and the temporary reduction of the appearance of cellulite. There is little or no downtime associated with this treatment. Ultimate Contour is not a weight-loss solution and it does not replace traditional methods such as diet, exercise or liposuction.

I agree to the terms & conditions

WHAT TO EXPECT

TEMPORARY SENSATIONS/SYMPTOMS

I may experience mild discomfort or slight tenderness in the treatment area may persist for a few hours following treatment, potentially extending to a few days.

I may experience short term bruising, swelling, redness (hyperemia), and/or ringing/buzzing in the ear(s) following a treatment. Contact our office if these symptoms worsen over time.

POTENTIAL SIDE EFFECTS / RISKS

It has been reported that “fatty” or cloudy urine and/or constipation have been reported following the use of ultrasound.
It is possible that neuromuscular stimulation, particularly on dry skin where an electric arc may occur, with the use of radio frequency.
Scarring and infection are rare occurrences, but are both a possibility if the skin surface is disrupted. To minimize the chances of scarring or infection, it is IMPORTANT that you follow all post-treatment instructions provided by your healthcare staff.
If the skin surface is disrupted, there is a possibility that the area may become either lighter (hypopigmentation) or darker (hyperpigmentation) in color compared to the surrounding skin. This is usually temporary, but, on a rare occasion, it may be permanent.
It is possible that the Ultrasound treatment may cause or aggravate Tinnitus or other hearing conditions. If you have sensitive ears or suffer from any hearing conditions you should not receive the treatment with the Ultrasound.
While rare, it is possible to experience temporary numbness after treatment.
I understand that these and other unknown side effects may also occur.

If you have any of the above listed side effects, please call us at 636-369-4043 to discuss.

I agree to the terms & conditions

RESULTS

I may start to see changes immediately following the treatment and my body will continue to naturally process the injured fat cells from my body over several months after the procedure. The actual results may vary by individual and there is no assurance I will achieve the results I am seeking. Although highly unlikely, it is possible that I will not experience any noticeable result from the procedure. Please discuss your progress with your provider before undergoing any further treatments.

I agree to the terms & conditions

Red Light Therapy

Your session includes 3 complimentary, 30 minute Detox appointments in a Red Light Therapy Bed . This treatment supports the body to get rid of destroyed fat cells and optimizes the results created by the body sculpting. Should you wish to learn more, visit the Light Lounge website

I understand that in order to receive my complimentary 30 minute Red Light Therapy Session, I must specify so on at the time of my appointment booking.

I DO want my complimentary Red Light Therapy session

I DO NOT want my complimentary Red Light Therapy session

Medical History

Infection in the target area
History of poor wound healing
History of keloid formation
Cardiac pacemakers or internal defibrillators
Heart disease or failure, aortic aneurism, or hypertension
Cancer or premalignant tissues
Malignant or benign tumors in the target area
Hernia in the treated areas
Multiple sclerosis
Arteriosclerosis or weakened blood vessels
History of hemophilia or bleeding disorders
Thrombosis or thrombophlebitis, wither acute or sub-acute
Any hyperlipidemia (high levels of cholesterol or triglycerides etc.)
Any thyroid disorders, diabetes or blood-glucose sensitivity
Any abnormal liver or kidney functions or other liver disease
Plastic or metal implants such as mesh, clips, stents, ports, etc.
Epilepsy
I have not had liposuction in the last 6 months.

If you have any of the above listed conditions, please call us at 636-369-4043 to discuss.

Please certify one of the following options

I certify that I do not experience or have been diagnosed with any of the above conditions.

I certify that I have been diagnosed with, or suspect that I have, one of the listed conditions.

If you marked you do have one of the above conditions, please list them.

Pregnancy

For women of childbearing age:

I confirm that I am not pregnant and do not intend to become pregnant anytime during the course of treatment. Furthermore, I agree to keep Beyond Body Sculpting, LLC and staff informed should I become pregnant during the course of treatment.

If you are pregnant, or trying to get pregnant, please call us at 636-369-4043 to discuss.

Please certify one of the following:

I certify that I understand and accept the above statements, and am not pregnant.

I am male.

HEARING

I acknowledge I do not have the following conditions:

History of any hearing condition like Meniere's or Tinnitus.

If you have any of the above listed conditions, please call us at 636-369-4043 to discuss.

Please certify one of the following:

I certify that I do not experience or have been diagnosed with any of the above conditions.

I certify that I have been diagnosed with a hearing condition

If you have been diagnosed or experience a hearing condition, please provide details here.

Informed Consent

By signing below, I acknowledge that the following points have been discussed with me. Potential benefits of the proposed procedure, including the possibility that the procedure may not work for me. Alternative treatments such as surgery. Reasonably anticipated health consequences if the procedure is not performed. Possible complications/risks involved with the proposed procedure and subsequent healing period. Pictures will be obtained for medical records. If pictures have been consented for use for education and marketing purposes, all identifying marks will be cropped or removed. I understand that it is IMPORTANT that I follow all post-treatment instructions provided by Beyond Body Sculpting, LLC providers and staff. I understand that it is IMPORTANT that I follow all post-treatment instructions provided by Beyond Body Sculpting, LLC providers and staff. While we make every effort to make our patients as happy as possible with their experience and results, all sales are final. Any used or unused treatments will not be refunded. As with most medical procedures, there are risks and side effects. These have been explained to me in detail. I have read the above information, and I give my consent to be treated with the Ultimate Contour procedure by the providers in this practice and his/her designated staff. I certify that I am competent adult of at least 18 years of age, or that, if I am a minor under the age of 18, I understand that the consent of my parent/guardian having legal custody will also be required before treatment. I agree and adhere to all safety precautions.

Please read and review Red Light Therapy Waiver and Informed Consent

Your signature below will certify that you understand and accept this document in its entirety:

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