Release of Liability for Body Contouring and Radio Frequency
I have voluntarily elected to undergo this treatment/procedure. The nature and purpose of this treatment has been explained to me, along with the risks and hazards involved
I also recognize there are no guaranteed results and that independent results are dependent upon age, skin condition, and lifestyle and that there is the possibility I may require further treatments of the treated areas to obtain the expected results at an additional cost. Although it is impossible to list every potential risk and complication, I have been informed of possible benefits, risks, and complications
I have read and understand the post-treatment home care instructions. I understand how important it is to follow all instructions given to me for post-treatment care. I understand that maintaining a balanced diet and excercise program is critical to my results
In the event that I may have additional questions or concerns regarding my treatment or suggested home product/post-treatment care, I will consult Body+ Soul immediately.
I have also, to the best of my knowledge, given an accurate account of my medical history, including all known allergies or prescription drugs,herbal supplements or products I am currently ingesting or using topically. I do not hold Body+Soul or the provider responsible for any skin condition that is present, but was not disclosed at the time of the skin care procedure which may be affected by the treatment performed today
I have read and fully understand this agreement and all information detailed above. I understand the procedure and accept the risks. All my questions have been answered to my satisfaction and I consent to the terms of this agreement
Do you have any of the following medical conditions?
Epilepsy, Kidney/Renal Failure, Liver Failure, Hypertriglyceridemia and Hypercholesterolemia, or Thyroid conditions.
If yes to the above question, please explain.
If yes, please list below.
If yes, please explain.