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This is an informed consent document which has been prepared to help TerryFit and staff inform you concerning VelaShape® III Treatment, its risks, likely effects and alternative treatments.

It is important that you read this information carefully and completely. Please sign the consent for this procedure as proposed by TerryFit and agreed upon by you, indicating that you have read the informed consent.

I understand that the VelaShape® III is a device used for improving the appearance of cellulite and reducing circumferences and that it may also be therapeutic for improving circulation and muscle aches in the treated areas. I understand there is a possibility of short-term effects such as discomfort, reddening, blistering, scabbing, temporary bruising and temporary discoloration of the skin, as well as rare side effects such as scarring and permanent discoloration. These effects have been fully explained to me.

I understand that clinical results may vary depending on individual factors, including but not limited to medical history, skin type, patient compliance with pre- and post-service instructions, and individual response to service.

I understand that the results are most effective when combined with exercise and a balanced, healthy diet. You may enquire about our existing plans with TerryFit to further support your Velashape III service.

I certify that I have been fully informed of the nature and purpose of the procedure, expected outcomes and possible complications, and I understand that no guarantee can be given as to the result obtained. I am fully aware that my condition is of cosmetic concern and that the decision to proceed is based solely on my expressed desire to do so.

I confirm that I have informed the staff regarding any current or past medical condition, disease or medication taken.

I certify that I have been given the opportunity to ask questions and that I have read and fully understand the contents of this consent form.

CONSENT

I understand and agree that all services rendered will be charged directly to me, and I am personally responsible for payment. I further agree, in the event of non-payment, to bear the cost of collection, and/ or court costs and reasonable legal fees should they be required. The fees charged for this procedure do not include any potential future costs for additional procedures that you elect to have or require in order to revise, optimize, or complete your outcome. Additional costs may occur should complications develop from the VelaShape® III and will also be your responsibility.

I agree to follow up with TerryFit at the recommended intervals to monitor the effectiveness of the service, and to contact TerryFit to advise of any change in my condition or any problem I may experience.

In signing this consent for this procedure, you acknowledge that you have read the informed consent and have been informed about its risks and consequences and accept responsibility for the clinical decisions that have been made, along with the financial costs of all services and future services. I understand that I have the right not to consent to this service and that my consent is voluntary.

I hereby release TerryFit from liability associated with this procedure. I give my informed consent for a VelaShape® III Treatment today as well as future services as needed.

First Client's Name

First Name*

Middle Name

Last Name*

Phone*
First Client's Date of Birth*
First Client's Signature*
Second Client's Name

First Name*

Middle Name

Last Name*
Second Client's Date of Birth*
Third Client's Name

First Name*

Middle Name

Last Name*
Third Client's Date of Birth*
Fourth Client's Name

First Name*

Middle Name

Last Name*
Fourth Client's Date of Birth*
Fifth Client's Name

First Name*

Middle Name

Last Name*
Fifth Client's Date of Birth*
Sixth Client's Name

First Name*

Middle Name

Last Name*
Sixth Client's Date of Birth*
Seventh Client's Name

First Name*

Middle Name

Last Name*
Seventh Client's Date of Birth*
Eighth Client's Name

First Name*

Middle Name

Last Name*
Eighth Client's Date of Birth*
Ninth Client's Name

First Name*

Middle Name

Last Name*
Ninth Client's Date of Birth*
Tenth Client's Name

First Name*

Middle Name

Last Name*
Tenth Client's Date of Birth*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Photograph Consent
I consent to the taking of photographs and authorize their anonymous use for the purposes of medical audit, education and promotion.*
Yes
No
Please fill out your CC information below to hold your appointment.
By completing the below details, I authorize my card to be charged for the full amount of the service in the event of a no-show or late cancellation (within 24 hours of time of service). Please be aware that there is a 3% charge for all CC transactions.*
Yes

Name as appears on card *
CC Type (Select One)*
Visa
Mastercard
Amex
Discover

Card Number *

Expiry Date (MM/YY) *

CVV Code *

Billing Address *

Billing Zip Code *

Email Address (Receipt Provided) *
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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