Pre-Treatment Consent Form

    Confidential Medical History Questionnaire

    Answer YES or NO to the following questions; if YES, give more details overleaf. If you do not understand any of the question please ask a member of staff.

    Treatment Restrictions

    (This may limit or restrict the treatment)

    Terms & Conditions

    Read this document carefully and if you agree that you have read the information leaflet, sign below.

    Everything about the above named procedure to your satisfaction; have checked that the information on this form and the Client Registration form are correct and only if you approve and consent, sign below.

    I authorise and consent to treatment for improving the appearance of cellulite/skin tightening using the procedure(s) listed on page 1.

    I have been advised of the advantages and disadvantages associated with the above procedure and I agree that the therapist has adequately explained the proposed procedure and alternatives.

    I understand that treatment experience and results with this procedure varies from client to client and as with all beauty therapy procedures, no guarantees can be made regarding the eventual outcome.

    I understand that the primary benefits are for personal effect and not for medical or essential health reasons.

    I am satisfied that I had enough “cooling off” opportunity to enable me to make a rational decision.

    I accept that the cosmetic improvements are secondary to a healthy lifestyle and sensible diet and that exercise regimes must be maintained.

    I have been given enough opportunities to ask questions and seek further information and have received satisfactory answers to all of them.

    I accept, although rare, that adverse outcomes such as pain, bleeding, bruising, infection, numbness, scarring and lumps may occur.

    I am aware that with relatively new procedures, there are no long-term studies on adverse effects and complications.

    I authorise the taking of photographs.

    I understand that use of such equipment is optional and entirely at my own risk.

    I have completed a medical questionnaire and can confirm that all information is correct.