Body Contouring

Informed Consent For Body Contouring

give my consent for body contouring to be performed by

Please read and initial each of the statements below:

I certify I am over the age of 18.

I have voluntarily elected to receive body contouring after the nature and purpose of this treatment has been explained to me.

I understand that body contouring can be used to reduce fat deposits, but is not intended to be a weight loss solution.

I understand that the following conditions preclude me from having this treatment at this time and verify that none of the following conditions apply to me at this time:

I recognize there are no guaranteed results.

I understand and acknowledge that there are risks involved with the treatment I will be receiving including, but not limited to:

I have been informed of possible benefits, risks, and complications, and I have had the opportunity to ask questions regarding these risks and other possible complications

I have, to the best of my knowledge, given an accurate account of my medical history, including all known allergies or prescription drugs or products I am currently ingesting or using topically.

I have read and fully understand this agreement and all information detailed above. I understand the procedure and accept the risks. I agree I will assume the risk and full responsibility for any and all injuries, losses, side effects, or damages which might occur to me while I am undergoing this procedure. I do not hold the technician responsible for any of my conditions that were present, but not disclosed at the time of this procedure, which may be affected by the treatment performed today.

Name Printed

First

Signature

Date

517-258-1988

517-258-1988

Informed Consent For Body Contouring

Body Contouring

Please read and initial each of the statements below:

HOURS OF OPERATION

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