LIPOLASER CONSULTATION AND CONSENT FORM – Consent Forms- Med Spa at Villagio

Name

Date

Date of Birth

Email Address

Sex:

Male Female

Lipo Laser is a new and innovative technology that has been approved for spot fat reduction and body contouring in Canada and Europe. In the U.S. Lipo Laser is presently approved for pain management, and doctors are using the device as off-label application for spot fat reduction and body contouring.

Lipo Laser is one of the tools that we can use to help you reach your goals and the real advantage of this technology lies in the fact that we can specifically target a trouble area. Once the fats have been released from the cell they can be used by the body as a fuel source. It is therefore critical that the dietary and lifestyle changes are made to help support the goals of treatment.

A reduced calorie diet and an exercise program that will help to burn approximately 350 – 500 calories post treatment are ideal. Individual results may vary and it is the responsibility of the client to ensure they are doing the appropriate home care to ensure maximum results. Clients should be consuming a caloric intake equivalent to their target weight (lbs) multiplied by 10. For example a 220lb male who wants to reach 200 lbs should be consuming a daily intake of 2000 calories. In some cases additional support may be required for lymphatic drainage to help stimulate the body to clear the fats that are released from the cell. Most clients experience a ½ inch reduction with each treatment and multiple inches can be lost with a series of treatments.

Please check to confirm the following:

I am over the age of 18 I am not pregnant or lactating I do not have epilepsy I do not have a pacemaker I do not have Herpes Simplex I do not have a life sustaining artificial heart-lung

I have no known liver or kidney disorders I have no known thyroid gland dysfunctions I do not have a compromised immune system I do not have cancer or a history of cancer I have no known photosensitivity to sun exposure I do not have uncontrolled Hypertension

Limitation to Treatment:

understand there are no guarantees as to the results of this treatment I understand there are no refunds for this treatment I understand that to achieve maximum results, I may require several treatments To achieve maximum results, I understand diet and regular exercise will assist to sustain and create accumulative degree of overall spot fat reduction and body contouring

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.......... in signing this agreement understand that I am beginning a series of treatments to help reach my goals of body contouring and spot fat reduction. I understand that individual results may vary and that I must commit to changing the dietary and lifestyle factors necessary to achieve optimal results.

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.

I consent to, and authorize Medspa at Villagio to perform the laser

treatment for the area of

Signature:

Date:

Printed name:

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.