Informed Consent and Release of Liability Form

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Name *

First

Last

DOR *

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?

Risk 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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I understand that a minimum of 9-12 treatments is required to achieve results at an average BMI of 25 to 30. A BMI over 30 (which is considered in the obese range) requires a specific strategy moving forward with the minimum recommendation of 24+ treatments. Each body is different and may require more or less treatments depending on the clients diet, exercise, metabolism and body type. I understand the treatment is most successful if I also maintain a healthy diet and commit to an exercise program.

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I know that if after the treatment program I gain weight, the results of the LipoMelt may be reversed.

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I understand that no guarantee has been given as to the results that may be obtained by this treatment. I have read this informed consent and certify that I understand its contents in full. I have had enough time to consider the information and feel I am sufficiently advised to consent to this procedure. I hereby give my consent to have this procedure. If at any time during the LipoMelt procedure I experience pain or discomfort of any kind, I agree to inform the staff immediately and/or terminate the session at my discretion

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I duly authorize technicians to perform the procedure for the purpose of body contouring, lymphatic drainage, improvement of cellulite, and skin tightening. I am aware that clinical results may vary depending on individual factors, medical history, patient compliance with pre/post treatment instructions, and individual response to treatment. If I do not make an effort to address my diet and exercise, the results achieved may not be retained.

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Whole Body Vibration Plate Machines are scientifically calibrated exercise machines designed to force your muscles to stretch and contract rapidly in small increments, replicating the same action which occurs during traditional exercising. Vibration exercises use your body weight and gravity to its fullest potential. Please do not use a whole body vibration plate or any other exercise device without getting approval from your doctor.
The device is not recommended if you are: pregnant, diabetic with complications such as neuropathy or retinal damage, have a pacemaker, recently underwent surgery, suffer from Epilepsy or Migraines, have herniated disks, spondylolisthesis, have cancer or tumors, have recent joint replacements, have metal pins or plates, or have any other concerns about your physical health. These contraindications do not mean that you are not able to use a vibration or other exercise device, bit it is recommended that you consult with your physician first.
I understand that using a whole body vibration machine is a strictly voluntary physical activity chosen by myself (the client). If at any time I experience pain or discomfort of any kind, I agree to inform that staff immediately and/or terminate the exercise.

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I have reviewed this consent form. My consent and authorization for this procedure are strictly voluntary. By signing the informed consent form I grant authority to perform the described treatment. The purpose of this procedure, risks, and complications have been fully explained to my satisfaction. Cosmetic indications for these procedures include by are not limited to cellulite reduction, treatment of problem fat areas, skin tightening, and skin rejuvenation. Increased redness to the area for up to 12 hours may be experienced (although this is unlikely). Normal activities may be resumed following the treatment. Any photos taken are voluntary and will be used to show the clients progress.

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PRIVACY POLICY

PRIVACY POLICY
We value your privacy, and are committed to maintaining your security and confidentiality in the use of any information you choose to share with us. We do not disclose identifiable information to any third party without your consent. Further, we do not sell, rent, or otherwise allow the unauthorized outside use of personal information such as names, addresses, phone numbers, or e-mail addresses in our database without your permission. Copies of this form and signature will be valid as if original if this document is digitally scanned. If any part of this Release is found to be invalid by the courts having jurisdiction, or becomes inoperative for any reason, such invalidity shall not affect the validity and enforceability of any other provision of this release.

CANCELLATION POLICY

CANCELLATION POLICY
We require a 24 hour cancellation notice.
*If I cancel within 24 hours of a reserved session, I will lose or forfeit my session. If I fail to show up or am more than 5 minutes late, I will lose or forfeit my session due to staff wages and fees paid for my session.
Our cancellation policy has been created to ensure that our loyal clients are not disturbed by the tardiness of clients who do not show up on time, or who cancel within 24 hours of an appointment. When reserved sessions are unattended, this means that loyal clients missed the opportunity of having that particular time period.

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PURCHASE & RESERVATION POLICY

PURCHASE & RESERVATION POLICY
Sessions will only be confirmed and allowed up to the amount of pre-paid sessions. All sales are final and non-refundable. We reserve the right to terminate any client’s sessions, package, or contract without refunding any monies if the client has broken any terms or policies. All purchases are final, non-refundable and non-transferable.
*I understand if I have purchased and pre-paid for a first time customer promotion (such as Groupon), that I may not use or purchase another first-time promotion without consent.

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Questions and Explanations

Questions and Explanations
By signing below, you certify that this procedure has been explained to you and that you have been fully informed of the nature and purpose of the LipoMelt procedure, expected outcomes and possible complications, and understand that no guarantee can be given as to the final results obtained. You are fully aware that your condition is of a cosmetic concern and that the decision to proceed is solely based upon your expressed desire to do so. You are aware that LipoMelt may/can cause slight hypo/hyper-pigmentation of the skin and treatment is taken at your own risk (tattoo areas should be avoided). Any further questions can be directed to a LipoMelt Specialist. Furthermore, you are of lawful age and legally competent to sign this aforementioned release, and that you understand the terms herein is contractual and not a mere recital; You have signed this document of your own free will.

I further state that I am of lawful age and legally competent to sign this aforementioned release. The procedures and risks have been explained to me and I have been given the opportunity to ask questions. I understand it is my responsibility to inform the staff if there are any changes to my medical history. I understand the terms herein is contractual and not a mere recital. I have signed this document of my own free act. I HAVE CAREFULLY READ, UNDERSTOOD AND ACKNOWLEDGE ALL OF THE ABOVE STATEMENTS. *

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