Consent and Release of Liability Form Informed
Consent Release and Indemnity Agreement
First Name
Last Name
Date of Birth
Program and Background
You have requested treatment utilizing
Skinny Beam
LED light therapy manufactured
Skinny
Beam. This treatment is
the application of a 635 nm light, which causes fat within the adipose (fat) cell to leave cell and accumulate in the
cells interstitial space, utilizing stimulating of its biological function to help the body break down fat. This excess fat
is moved 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 its risk. LED therapies have been approved by the FDA.
Procedure
Initially you will consult with a
Skinny Beam
therapist 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 paperwork, measurements, pre and post treatment
photos (upon your approval) a n d suggested course of
treatment will be given. The treatment is administered by
placing up to 4LED pads on the desired area(s) to be treated. It is recommended that a patient will need a
minimum of 9 – 12 treatments for the Light LED therapy to achieve its desired effect. This treatment should be
used in conjunction with a healthy diet and exercise. You should consult a health care professional before
beginning any new exercise program to determine if your body is physically able.
Risks/Discomfort
This treatment is non‐invasive. During treatment there should be no discomfort, the client will feel the warmth
of the light.
Skinny Beam
is suitable for anyone over 18. Anyone with any of the following would not be
suitable for this treatment: pregnant, breast feeding, kidney or liver disease, cancer, auto‐immune disease.
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 lost from their stomach, hips, and thighs. These results do vary and no
guarantee is implied or suggested that desired results will be achieved.
IZ Call for Appt: 512 – 814 - 5522