Informed Consent and Release of Liability Form
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Program & Background

Program & Background
You have requested treatment utilizing LipoMelt LED light therapy. This treatment is the application of a 635nm and 880nm light, which cause fat within the adipose (fat) cell to leave and accumulate in the interstation space. Fat cells are not destroyed. This excess fat is removed by the body’s lymphatic system and excreted without negative side effects or downtime. Any medical or cosmetic procedure carries risks, complications and varied results. The purpose of this document is to inform of the nature of this product and it’s risk. LED therapies have been approved by the FDA.

Procedure

Procedure
Initially you will consult with a LipoMelt technician to determine if you are a candidate for the LED therapy. You will have the opportunity to ask questions or voice concerns you may have regarding this treatment. If it is determined you are a candidate for this procedure, then measurements, pre and post treatment photos (upon your approval) and suggested course of treatment will be given. The treatment is administered by placing up to 6 LED pads on the desired area(s) to be treated. Most clients will need a minimum of 10-12 treatments for the Light LED therapy to achieve its desired effect. This effectiveness of this treatment can be different for each person. Results are not guaranteed. This treatment should be used in conjunction with a healthy diet and exercise. Weight gain will reverse the effects of this treatment. You should consult a healthcare professional before beginning any new exercise program to determine if your body is physically able.

Please initial and answer the questions below.

Risk/Discomfort

Risk/Discomfort
This treatment is non-invasive. During treatment there should be no discomfort. The client may feel the warmth of the light. LipoMelt is suitable for anyone over 18 who does not have any of the following issues: Pregnancy, Breast Feeding, Recent or Current Cancer, Heart Disease, Pacemaker or Metal Pins or Plates.

Do you have any of the above conditions?

Benefits

Benefits
LED light therapy has become more prominent and has been used in many studies for pain management and recently by cosmetic surgeons to emulsify adipose before liposuction with FDA approval. The potential benefit of this treatment is body contouring without surgery. Problem areas or excess pockets of fat can be targeted, however the most commonly treated areas are the stomach, hips, flanks, and thighs. In clinical trials patients have averaged 2-5cm loss from their stomach, hips, and thighs. These results vary and no guarantee is implied or suggested that desired results will be achieved.

Voluntary Cosmetic Procedure

Voluntary Cosmetic Procedure
I understand that this is a strictly voluntary cosmetic procedure. No treatment is necessary or required and the LipoMelt LED therapy has been chosen by myself (the client).

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If you’re a current patient, please do not use this as a form of communication.