Lipofirm Consent Form

Patient’s Name:
File No.:
DOB:
Mobile Number:
Visit Date:
Registration Time:
Doctor Name:

I duly authorize the practitioners of.. to perform the Lipofirm Pro procedure for the purpose of spot fat reduction / improving the appearance of cellulite/ face and body skin tightening. I am aware that clinical results may vary depending on individual factors, including medical history, client compliance with pre/post treatment instructions, and individual response to treatment. I have been made aware that my diet and the amount of exercise I do, will have a major effect on the results of my treatments. If I do not make an effort to address my dietary requirements and exercise, I am aware that the results achieved may not be retained. I understand the treatment involves a course of treatments. The fee structure has been fully explained and I understand that I am required to pay for a course of treatments prior to any procedures taking place. I am fully aware that should I wish to cancel the course the outstanding treatment value is nonrefundable.

The course cost is E (Client initials) 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 final result obtained. I am fully aware that my condition is of a cosmetic concern and that the decision to proceed is based solely on my expressed desire to do so. I understand that it is my personal responsibility to inform the practitioner of the clinic named above of any changes to my medical history during the course of Lipofirm Pro treatment sessions for face or body and I confirm that should this occur I shall advise the practitioner of any changes. I consent to the taking of photographs and authorize their anonymous use for the purposes of medical audit, education and promotion. Delete if preferred. I certify that I have been given the opportunity to ask questions, any questions have been answered to my satisfaction and that I have fully read and understood the contents of this consent form. I understand that these questions are given with regard to my safety and well-being. I have answered all questions to the best of my knowledge and happy to proceed with Lipfirm Pro treatments for face and body.

I understand and agree that I am financially responsible for the payment I made for that any amount I paid for the sessions or procedures I booked it will only be valid up to 3 months from the date I made the payment. I understand that I need to utilize the sessions or procedures within 3 months period. I agree that my payment made is non-refundable or non-transferable post this period.

I declare that I have read and fully understood all points in this consent and that all of my questions were answered to my satisfaction and I take the full responsibility of my decision in this consent.

 

Patient Name & Signature :   

Doctor/Therapist Name & Signature :   


Parent or Gaurdian Name (if patient is minor) :

Date :