Consent Release And Indemnity Agreement printable pdf download

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

Consent Release And Indemnity Agreement