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Body Sculpting

Consent Form

The Body Sculpting procedure uses a non-invasive vacuum applicator to draw in tissue and deliver controlled cooling at the surface of the skin. The procedure is for spot reduction of fat. It is not a weight-loss solution. Someone who is overweight can expect to see less visible improvement than someone who has smaller fat deposits. Clinical studies have shown that Body Sculpting will naturally remove fat cells but, as with most procedures, visible results will vary from person to person.

WHAT TO EXPECT- The suction pressure may cause sensations of deep pulling, tugging, and pinching. You may experience intense stinging, tingling, aching or cramping as the treatment begins. These sensations generally subside as the area becomes numb. The treated area may look or feel stiff after the procedure and transient blanching (temporary whitening of the skin) may occur. You may feel a sense of nausea or dizziness as your body naturally warms and sensation returns to your treatment area. These are all normal reactions that typically resolve within minutes. Bruising, swelling, and tenderness can occur in the treated area and it may appear red for a few hours after the applicator is removed. You may feel a dulling sensation in the treated area that can last for several weeks after your procedure. Other changes including deep itching, tingling, numbness, tenderness to the touch, pain in the treated area, strong cramping, muscle spasms, aching and/or soreness. Some clients may experience a delayed onset of the previously mentioned occurrences. Contact us immediately if any unusual side effects occur or if symptoms worsen over time. You may start to see changes as early as three weeks after Body Sculpting, and you will experience the most dramatic results after one to three months. Your body will continue naturally to process and remove the injured fat cells from your body for approximately four months after your procedure. You may decide that additional treatments are needed to reach your desired outcome. In rare cases, clients have reported hardness, discrete nodules or a paradoxical enlargement of the treatment area. It is important you understand that these and other unknown side effects may occur. The degree of fat loss and duration of the effect may vary in different people. Payment is expected at the time of the treatment, which is before the extent of success is determined. Pictures will be obtained for medical records.

April 28, 2025

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's 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*
Second Participant's Date of Birth*
Second Participant's 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*
Third Participant's Date of Birth*
Third Participant's 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*
Fourth Participant's Date of Birth*
Fourth Participant's 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*
Fifth Participant's Date of Birth*
Fifth Participant's 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*
Sixth Participant's Date of Birth*
Sixth Participant's 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*
Seventh Participant's Date of Birth*
Seventh Participant's 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*
Eighth Participant's Date of Birth*
Eighth Participant's 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*
Ninth Participant's Date of Birth*
Ninth Participant's 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*
Tenth Participant's Date of Birth*
Tenth Participant's 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*
Parent or Guardian's 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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