Informed Consent

Informed Consent Body Contouring/Skin Tightening

In order to provide you with the most appropriate laser treatment, we need you to complete the following questionnaire. All information is strictly confidential.

Personal History

First Name

Last Name

Treatment Sites:

I hereby authorize a Treatment Professional and/or such assistants as may be selected to perform the following procedure and/or treatment:

I understand that there is a possibility of short-term side effects from the treatment. I could experience edema (swelling), prolong redness in the area treated as well as slight heat discomfort/tingling. The side effects have been fully explained to me during my consultation/treatment

I acknowledge that patient results may vary depending on many factors including, but limited to, medical history, and individual's response to treatment; patient compliance with pre and post treatment instructions or changes in medical condition prior to, during or after treatment has been completed.

I agree (if required/requested to the photographing of appropriate portions of my body for medical, scientific or educational purposes, provided they do not reveal my identity.

I understand that the treatment protocol involves a series of treatments with a specific protocol involved along with a fee structure associated to the series. I agree to follow this treatment protocol and fee structure as it was explained to me:

It has been explained to me by my physician and/or assistants in a way that I understand:

The above treatment or procedure to be undertaken

There are risks to the procedure/treatment proposed and I have been explained on what those risks are

There is no guarantee on the final results that I will obtain

The decision to proceed is based solely on my expressed desire to do so

I have informed the staff regarding any current or past medical condition, disease or medication that I am taking

Any questions I may have asked have been answered to my satisfaction

I consent to the treatment or procedure and the above listed items

Date