Informed Consent for Non-Surgical Body Contouring and/or Skin Therapies
I understand that certain procedure(s) elected are relatively new and little is known about their long-term safety and effectiveness. I understand that each person has a different response to Body Contouring.
I understand that the procedure(s) do not correct health problems, including but NOT limited to diabetes, heart attack, stroke, high cholesterol, blood clots, lung problems, stomach, intestinal problems, bladder disease, an abnormality of the skin is not a medical facility and does NOT make medical decisions. You must consult with your Primary Care Physician for medical advice.
I understand that I may need post procedure care. I will dutifully be responsible and compliant with the recommendations from my Clinician, which may include, but are not limited to skin care products, garments, diet, etc.
I understand that procedures involve risk. Risk may include, but not limited to redness, swelling, irritation, burns, skin reactions, etc. I must immediately report any unusual symptoms known to me to my Clinician that includes, but NOT limited to being aware of any slight nature or prominence of persistent chills, fever, redness, increased warmth, excessive bruising or swelling, etc. at the sights treated and systematically.
I give permission to use data about my treatment for research purposes. I understand that my name and personal identifying information will remain confidential unless I have written permission to disclose this information. I give professional permission to photograph/video my procedure(s).
I have decided that the benefits of body contouring outweigh the potential for complications and all claims have not been evaluated by any regulatory board. I understand the nature of the procedure(s) and ANY and all possible risks mentioned and not limited to. I attest that I am of clear mind, competent, and not under any distress.
Alternative Treatments
Cancellation Policy
Each booking requires a card on file to charge at the end of your service. You can cancel your booking up to 24 hours before the scheduled time without any fees. Bookings cancelled within the 24 hour window of the scheduled time will be charged a partial cancellation fee equal to 25% of the booking or $50 for smaller priced services.
Time Limits for Service
Release of Liability
Therein certify that I am not pregnant or nursing. I understand that NO GUARANTEES OR WARRANTIES have been made to me regarding the outcome or any improvements to my condition due to the procedure(s) I have elected to undergo. I am paying for a service and not desired results from treatments. I have been given the opportunity to ask questions and have received satisfactory answers to those questions by the treating staff representative.
I consent to the taking of photographs/video for documentation during my treatments) unless otherwise stated with written notice to These photos may be used for marketing and/or publication for the further benefit of educating the public. All attempts will be made to protect my identity.
I agree to indemnify, hold harmless and release , its employees, members, representatives, affiliated organizations, and others acting on the Company’s behalf of all claims, demands, causes of action and legal liability, whether the same be known or unknown, anticipated or unanticipated. I further agree that in except in the events of the Company’s gross negligence or willful misconduct, no claims, demands, legal actions and causes of action shall be made against the Company for any economic and non-economic losses of any kind.
I am aware that there is a worldwide pandemic circulating called Covid-19. I am aware that has been trained in Infectious Disease Control and is taking all necessary precautions to insure my safety in this environment. However, body contouring is an elective service and I am participating in such services at my own risk. I will not hold responsible if I test positive for Covid-19.
Finally, I certify that I have read and fully understand the contents of this form and that the disclosures referred to the above were made prior to my signing the form below.