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Body Sculpting

Consent Form

BODY SCULPTING – INFORMED CONSENT

Body Sculpting is a non-invasive cosmetic procedure that uses a vacuum applicator to draw targeted tissue into the applicator while delivering controlled surface cooling to the skin. The purpose of this treatment is localized (spot) reduction of fat in specific areas of the body.

I understand that Body Sculpting is not a weight-loss procedure and is not intended to treat obesity. Individuals with larger or more diffuse fat deposits may experience less visible or less noticeable improvement compared to individuals with smaller, localized areas of fat.

While clinical studies indicate that Body Sculpting can result in the natural reduction of fat cells over time, I understand that results vary significantly from person to person, and no specific outcome can be guaranteed.

WHAT TO EXPECT DURING AND AFTER TREATMENT

During treatment, the vacuum suction may cause sensations including deep pulling, tugging, pinching, pressure, or tightness. As cooling begins, I may experience intense cold, stinging, tingling, aching, cramping, or burning sensations, particularly at the start of the procedure. These sensations typically diminish as the area becomes numb.

Immediately following treatment, the treated area may:

  • Feel firm, stiff, or hardened
  • Appear red, swollen, bruised, or tender
  • Show temporary blanching (whitening of the skin)
  • Feel numb or have reduced sensation

As sensation returns, I may experience:

  • Tingling or itching
  • Aching, soreness, or sensitivity
  • Muscle cramping or spasms
  • Nausea, dizziness, or lightheadedness
  • These reactions are generally temporary and often resolve within minutes to hours, but some may persist longer.

POSSIBLE SIDE EFFECTS AND RISKS

I understand that Body Sculpting, like all cosmetic procedures, carries known and potential risks, including but not limited to:

Common or Expected Side Effects

  • Bruising
  • Swelling
  • Redness
  • Tenderness or soreness
  • Temporary numbness or altered sensation
  • Itching or tingling
  • Dull or aching sensations lasting days to weeks

Skin Changes and Pigmentation Risks

  • Hyperpigmentation (darkening of the skin)
  • Hypopigmentation (lightening of the skin)
  • Uneven skin tone or discoloration
  • Temporary or prolonged redness
  • Changes in skin texture
  • Sensitivity to touch

Pigmentation changes may be temporary or permanent, and may be more noticeable in individuals with darker skin tones or a history of pigmentation disorders.

Less Common or Delayed Reactions

  • Prolonged numbness or nerve sensitivity
  • Pain or hypersensitivity
  • Firmness, hardness, or palpable nodules
  • Asymmetry or uneven results
  • Delayed onset of discomfort or sensory changes

Rare but Reported Risks

  • Paradoxical adipose hyperplasia (unexpected enlargement or hardening of the treated area)
  • Persistent pain
  • Long-term sensory changes
  • Scarring (rare)
  • Nerve irritation or injury

I understand that unknown or unforeseen side effects may occur, as not all reactions can be predicted.

RESULTS AND OUTCOME EXPECTATIONS

I understand that:

  • Visible changes may begin as early as three (3) weeks
  • Most noticeable results typically appear one (1) to three (3) months post-treatment
  • My body will continue to naturally process and eliminate affected fat cells for up to four (4) months
  • Additional treatments may be necessary to achieve my desired results
  • Results are not guaranteed, and the degree and duration of fat reduction varies between individuals

POST-TREATMENT CARE AND RESPONSIBILITY

I agree to follow all post-treatment instructions provided by Laser Luxury. I understand that failure to follow aftercare instructions may increase the risk of complications or affect results.

I agree to contact Laser Luxury immediately if I experience:

  • Severe or worsening pain
  • Unusual skin reactions
  • Signs of infection
  • Symptoms that persist or worsen over time

PAYMENT AND PHOTOGRAPHY

I understand that payment is due at the time of treatment, prior to knowing the final outcome or extent of results.

I consent to clinical photographs being taken before and after treatment for medical records, treatment evaluation, and documentation purposes.

ACKNOWLEDGMENT AND CONSENT

By signing below, I acknowledge that:

  • I have had the opportunity to ask questions
  • All my questions have been answered to my satisfaction
  • I understand the procedure, risks, benefits, alternatives, and limitations
  • I voluntarily consent to undergo Body Sculpting treatment
First Participant's Name
First Name*
Last Name*
Phone*
First Participant's Date of Birth*
Date of Birth
Information
Do you have any of the following? If so, Check.
Cryoglobulinemia or paroxysmal cold hemoglobinuria
Known sensitivity to cold such as cold urticaria or Raynaud’s disease
Impaired peripheral circulation in the area to be treated
Neuropathic disorders such as post-herpetic neuralgia or diabetic neuropathy
Bleeding disorders or concomitant use of blood thinners
Recent surgery or scar tissue in the area to be treated
A hernia or history of hernia in the area to be treated
Impaired skin sensation
Open or infected wounds
Skin conditions such as eczema, dermatitis, or rashes
Any active implanted devices such as pacemakers and defibrillators

As with most medical procedures, there are risks and side effects. These have been explained to me in detail. I have read the above information, and I give my consent to be treated with Body Sculpting.

I also give permission for my credit card on file to be charged in the event I cancel or reschedule within 24 hours of my appointment. Please check box
First Participant's Signature*
Second Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Do you have any of the following? If so, Check.
Cryoglobulinemia or paroxysmal cold hemoglobinuria
Known sensitivity to cold such as cold urticaria or Raynaud’s disease
Impaired peripheral circulation in the area to be treated
Neuropathic disorders such as post-herpetic neuralgia or diabetic neuropathy
Bleeding disorders or concomitant use of blood thinners
Recent surgery or scar tissue in the area to be treated
A hernia or history of hernia in the area to be treated
Impaired skin sensation
Open or infected wounds
Skin conditions such as eczema, dermatitis, or rashes
Any active implanted devices such as pacemakers and defibrillators

As with most medical procedures, there are risks and side effects. These have been explained to me in detail. I have read the above information, and I give my consent to be treated with Body Sculpting.

I also give permission for my credit card on file to be charged in the event I cancel or reschedule within 24 hours of my appointment. Please check box
Third Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Do you have any of the following? If so, Check.
Cryoglobulinemia or paroxysmal cold hemoglobinuria
Known sensitivity to cold such as cold urticaria or Raynaud’s disease
Impaired peripheral circulation in the area to be treated
Neuropathic disorders such as post-herpetic neuralgia or diabetic neuropathy
Bleeding disorders or concomitant use of blood thinners
Recent surgery or scar tissue in the area to be treated
A hernia or history of hernia in the area to be treated
Impaired skin sensation
Open or infected wounds
Skin conditions such as eczema, dermatitis, or rashes
Any active implanted devices such as pacemakers and defibrillators

As with most medical procedures, there are risks and side effects. These have been explained to me in detail. I have read the above information, and I give my consent to be treated with Body Sculpting.

I also give permission for my credit card on file to be charged in the event I cancel or reschedule within 24 hours of my appointment. Please check box
Fourth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Do you have any of the following? If so, Check.
Cryoglobulinemia or paroxysmal cold hemoglobinuria
Known sensitivity to cold such as cold urticaria or Raynaud’s disease
Impaired peripheral circulation in the area to be treated
Neuropathic disorders such as post-herpetic neuralgia or diabetic neuropathy
Bleeding disorders or concomitant use of blood thinners
Recent surgery or scar tissue in the area to be treated
A hernia or history of hernia in the area to be treated
Impaired skin sensation
Open or infected wounds
Skin conditions such as eczema, dermatitis, or rashes
Any active implanted devices such as pacemakers and defibrillators

As with most medical procedures, there are risks and side effects. These have been explained to me in detail. I have read the above information, and I give my consent to be treated with Body Sculpting.

I also give permission for my credit card on file to be charged in the event I cancel or reschedule within 24 hours of my appointment. Please check box
Fifth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Do you have any of the following? If so, Check.
Cryoglobulinemia or paroxysmal cold hemoglobinuria
Known sensitivity to cold such as cold urticaria or Raynaud’s disease
Impaired peripheral circulation in the area to be treated
Neuropathic disorders such as post-herpetic neuralgia or diabetic neuropathy
Bleeding disorders or concomitant use of blood thinners
Recent surgery or scar tissue in the area to be treated
A hernia or history of hernia in the area to be treated
Impaired skin sensation
Open or infected wounds
Skin conditions such as eczema, dermatitis, or rashes
Any active implanted devices such as pacemakers and defibrillators

As with most medical procedures, there are risks and side effects. These have been explained to me in detail. I have read the above information, and I give my consent to be treated with Body Sculpting.

I also give permission for my credit card on file to be charged in the event I cancel or reschedule within 24 hours of my appointment. Please check box
Sixth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Do you have any of the following? If so, Check.
Cryoglobulinemia or paroxysmal cold hemoglobinuria
Known sensitivity to cold such as cold urticaria or Raynaud’s disease
Impaired peripheral circulation in the area to be treated
Neuropathic disorders such as post-herpetic neuralgia or diabetic neuropathy
Bleeding disorders or concomitant use of blood thinners
Recent surgery or scar tissue in the area to be treated
A hernia or history of hernia in the area to be treated
Impaired skin sensation
Open or infected wounds
Skin conditions such as eczema, dermatitis, or rashes
Any active implanted devices such as pacemakers and defibrillators

As with most medical procedures, there are risks and side effects. These have been explained to me in detail. I have read the above information, and I give my consent to be treated with Body Sculpting.

I also give permission for my credit card on file to be charged in the event I cancel or reschedule within 24 hours of my appointment. Please check box
Seventh Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Do you have any of the following? If so, Check.
Cryoglobulinemia or paroxysmal cold hemoglobinuria
Known sensitivity to cold such as cold urticaria or Raynaud’s disease
Impaired peripheral circulation in the area to be treated
Neuropathic disorders such as post-herpetic neuralgia or diabetic neuropathy
Bleeding disorders or concomitant use of blood thinners
Recent surgery or scar tissue in the area to be treated
A hernia or history of hernia in the area to be treated
Impaired skin sensation
Open or infected wounds
Skin conditions such as eczema, dermatitis, or rashes
Any active implanted devices such as pacemakers and defibrillators

As with most medical procedures, there are risks and side effects. These have been explained to me in detail. I have read the above information, and I give my consent to be treated with Body Sculpting.

I also give permission for my credit card on file to be charged in the event I cancel or reschedule within 24 hours of my appointment. Please check box
Eighth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Do you have any of the following? If so, Check.
Cryoglobulinemia or paroxysmal cold hemoglobinuria
Known sensitivity to cold such as cold urticaria or Raynaud’s disease
Impaired peripheral circulation in the area to be treated
Neuropathic disorders such as post-herpetic neuralgia or diabetic neuropathy
Bleeding disorders or concomitant use of blood thinners
Recent surgery or scar tissue in the area to be treated
A hernia or history of hernia in the area to be treated
Impaired skin sensation
Open or infected wounds
Skin conditions such as eczema, dermatitis, or rashes
Any active implanted devices such as pacemakers and defibrillators

As with most medical procedures, there are risks and side effects. These have been explained to me in detail. I have read the above information, and I give my consent to be treated with Body Sculpting.

I also give permission for my credit card on file to be charged in the event I cancel or reschedule within 24 hours of my appointment. Please check box
Ninth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Do you have any of the following? If so, Check.
Cryoglobulinemia or paroxysmal cold hemoglobinuria
Known sensitivity to cold such as cold urticaria or Raynaud’s disease
Impaired peripheral circulation in the area to be treated
Neuropathic disorders such as post-herpetic neuralgia or diabetic neuropathy
Bleeding disorders or concomitant use of blood thinners
Recent surgery or scar tissue in the area to be treated
A hernia or history of hernia in the area to be treated
Impaired skin sensation
Open or infected wounds
Skin conditions such as eczema, dermatitis, or rashes
Any active implanted devices such as pacemakers and defibrillators

As with most medical procedures, there are risks and side effects. These have been explained to me in detail. I have read the above information, and I give my consent to be treated with Body Sculpting.

I also give permission for my credit card on file to be charged in the event I cancel or reschedule within 24 hours of my appointment. Please check box
Tenth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Do you have any of the following? If so, Check.
Cryoglobulinemia or paroxysmal cold hemoglobinuria
Known sensitivity to cold such as cold urticaria or Raynaud’s disease
Impaired peripheral circulation in the area to be treated
Neuropathic disorders such as post-herpetic neuralgia or diabetic neuropathy
Bleeding disorders or concomitant use of blood thinners
Recent surgery or scar tissue in the area to be treated
A hernia or history of hernia in the area to be treated
Impaired skin sensation
Open or infected wounds
Skin conditions such as eczema, dermatitis, or rashes
Any active implanted devices such as pacemakers and defibrillators

As with most medical procedures, there are risks and side effects. These have been explained to me in detail. I have read the above information, and I give my consent to be treated with Body Sculpting.

I also give permission for my credit card on file to be charged in the event I cancel or reschedule within 24 hours of my appointment. Please check box
Parent or Guardian's Email Address
Email*
Confirm Email*
Check to receive information, news, and discounts by e-mail.
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
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.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Last Name*
Phone*
Parent or Guardian's Date of Birth*
Date of Birth
Information
Do you have any of the following? If so, Check.
Cryoglobulinemia or paroxysmal cold hemoglobinuria
Known sensitivity to cold such as cold urticaria or Raynaud’s disease
Impaired peripheral circulation in the area to be treated
Neuropathic disorders such as post-herpetic neuralgia or diabetic neuropathy
Bleeding disorders or concomitant use of blood thinners
Recent surgery or scar tissue in the area to be treated
A hernia or history of hernia in the area to be treated
Impaired skin sensation
Open or infected wounds
Skin conditions such as eczema, dermatitis, or rashes
Any active implanted devices such as pacemakers and defibrillators

As with most medical procedures, there are risks and side effects. These have been explained to me in detail. I have read the above information, and I give my consent to be treated with Body Sculpting.

I also give permission for my credit card on file to be charged in the event I cancel or reschedule within 24 hours of my appointment. Please check box
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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