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Ultrasonic Cavitation and RF Consent Form

To register to our Spa please fill out the following consent form

First Name

Email Address

Last Name

Date of Birth

Are you pregnant or breast feeding

No

Yes

Heart problems or diseases

No

Yes

High blood presure

No

Yes

Active implanted devices such as a pacemaker or defibrillator

No

Yes

Cancer

No

Yes

Kidney damage / diseases

No

Yes

Liver damage / diseases

No

Yes

Acute inflamatory processes

No

Yes

Medical plastic parts or parts with metal inside

No

Yes

Abnormal immune system

No

Yes

Numb or insenitve to heat

No

Yes

Skin conditions such as eczema, dermatitis or rashes

No

Yes

Pictures may be obtained for clinical records. If pictures are used for education or marketing purposes, all identifying marks will be cropped or removed.

The benifits and potential side effects associated with ultrasonic cavitation and /or radiofrequency procedure have been explained to me in detail. I have read the information above and give my consent to be treated with ultrasonic cavitation and /or radio frequency

I accept terms & conditions

I declare that the info I’ve provided is accurate & complete

Initials

Today's Date

Thanks for submitting!