Consent Release And Indemnity Agreement (Page 2 of 7) in pdf

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.

Voluntary Cosmetic Procedure

Initial I understand that this is a strictly a voluntary cosmetic procedure. No treatment is necessary or

required and the

LED therapy has been chosen by me (the client).

Skinny Beam

Initial I have been informed of the potential risks and side effects of Skinny Beam including but not limited to

redness, swelling, heat sensitivity, pain, increase bowel movements and increased urination. The risks, potential damages

and adverse side effects have been explained to me and I fully understand.

Initial I understand that a minimum of 9 ‐‐12 treatments is required to achieve full results at an average BMI of 25

to 30. A BMI of over 30 (which is considered in the obese range) requires a specific strategy moving forward with the

minimum recommendation of 24 + treatments. At that point, I will be re‐evaluated to see if more sessions are needed in

order to achieve realistic goals.

Each body is different and may require more or less treatments depending on the client’s 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.

Initial I understand that if I gain weight after the treatment course, the results of the

Skinny Beam

will be reversed.

Initial 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

procedure I experience pain or discomfort of any kind, I agree to inform

Skinny Beam

the staff immediately and/ or terminate the session at my discretion.

Initial 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.

Initial 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 us to perform the described treatment. The purpose of this

procedure, risks, complications, alternative methods of treatment have been fully explained to my satisfaction. Cosmetic

indications for these procedures include but 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 will be used to show the clients

progress and may be used in marketing ads.

IZ Call for Appt: 512 – 814 - 5522

Consent Release And Indemnity Agreement Page 2