Change your Body & Mind

I 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 do not suffer migraine or severe headache.
___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
___I do not have uncontrolled Hypertension

LIMITATION TO TREATMENT:
I understand there are no guarantees as to the results of this treatment as each individual’s results will vary.
I understand that to achieve results, I will require several treatments.
I understand there are no refunds for this treatment.
I understand diet and consistent exercise and following the pre/aftercare list is critical to achieve and sustain results.
I understand this treatment is for cosmetic body sculpting and is not a medical weight loss treatment.

RISKS:
I have been informed and I understand that some mild side effects may be experienced after undergoing the
treatment including but not limited to: temporary ringing in the ears, transient redness of the skin, skin irritation,
nausea, increased thirst, headache, decreased appetite, hyper-pigmentation / hypo-pigmentation, or a minor burn
(on rare occasions) may occur as a result of treatment. We make every effort to avoid these contraindications.
However, it may happen which could cause a delay in treatment in that specific area. I hereby certify that all
information that I have provided has been accurate and truthful.
I hereby authorize to perform radio frequency and ultrasound cavitation procedures for the purpose of aesthetic body contouring.

CLIENT AGREEMENT:
In signing this agreement understand that I am beginning a series of treatments to help reach my goals of body contouring and the cosmetic treatment of certain areas and is not a medical procedure. I understand that individual results may vary and I must commit to changing the dietary and lifestyle factors necessary to achieve optimal results. I understand body sculpting is NOT for the treatment of obesity and will not aid in weight loss.
100% certainty of success cannot be assured as with any cosmetic treatment. It is also important to note that in the vast majority of cases, supported by clinical evidence, clients achieve results. Results may vary and therefore not meet expectations of all clients completing a full series of treatments. NO REFUNDS will be issued.
I have read and fully understand this consent 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 plan or any questions whatsoever concerning the proposed treatment or other possible treatments, ask your doctor or nurse now before signing this consent form.