LIPOLASER CONSULTATION AND CONSENT FORM

LIPOLASER CONSULTATION AND CONSENT FORM

Possible Risks:
  • I have been informed and I understand the temporary hyperpigmentation / hypopigmentation on rare occasion may occur as a result of treatment.
  • I hereby certify that all information that I have provided has been accurate and truthful.
  • I hereby authorize MedSpa at Villagio to perform Lipo Laser procedures for the purpose of aesthetic body contouring and girth.

I understand that the first step to a positive change is creating awareness about the steps necessary to reach these goals, and will work diligently to ensure success. I understand that much of the success of the program will depend on my efforts and that there are no guarantees or assurances that the program will be successful. I realize there may be pre-existing medical conditions that can preclude me from seeing optimal results. By signing this agreement, I release the spa/clinic, manufacturer and distributors from any liability regarding this treatment and do so understanding that results can vary from one individual to the next.

I have read and fully understand this consent form and I realize I should not sign this form if all items have not been explained to me. My questions have been answered to my complete satisfaction. I have been urged and have been given all the time I need to read and understand this form. If you have any questions regarding the risks or hazards of the proposed treatment, or any questions whatsoever concerning the proposed treatment or other possible treatments, ask your doctor now before signing this consent form.

Ensure your best results:
  • Don’t eat 2 to 4 hours prior to treatment
  • Drink plenty of water after every treatment.
  • Manage caloric intake; excess calories will counteract the laser treatments.
  • Alcoholic beverages and high sugar content drinks must be avoided before and after treatment.
  • Incorporate Whole Body Vibration (WBV) post treatment for 10 minutes or ensure you undertake physical activity following each treatment to maximize your results.

My signature herein constitutes my acknowledgement that I am a competent, consenting adult of at least 18 years of age (or my parent or legal guardian is giving consent on my behalf), and further, that I:

  • Have read and understand the information provided in the form.
  • Have had my procedure adequately explained to me.
  • Have had the opportunity to ask questions, and all of my questions have been answered to my satisfaction.
  • Have received all the information I desire concerning my procedure.
  • Understand all post treatment recommendations and agree to adhere to them.
  • Freely assume any risks of complications or injury from known or unknown causes associated with, relating to, or otherwise arising out of this procedure.
  • Have the right to consent to or refuse any proposed procedure at any time prior to its performance.
  • Must notify the clinician if my medical history changes prior to subsequent treatments.
  • Consent to photographs of the treatment area.

100% certainty of success cannot be assured as with any medical procedure. It is also important to note that in the vast majority of cases, supported by clinical studies, patients achieve results. Results may vary and therefore not meet expectations of all patients completing a full series of treatments. No refunds will be issued.