Slimming Consent Form

Procare XP / Cavitation for slimming and body sculpting machine

I understand that treatment is intended for reduction in the circumference:

1. It is non–invasive and non-contact way of delivering RF energy to target area so that creates deep heat for inducing fat cells destructions.

2. May feel optimal heat sensation on target area including overall parts of body. May also feel excessive heat sensation on certain area with pain, and it should be informed to a clinician if there is any kinds of discomfort occurred.

3. Should be diagnosed by the clinician if there is any prolonged tenderness, heat sensation, edema, or redness has occurred after treatment.

4. There could be a possibility of inflammation of tissues

Contradictions:

• Implanted electronic devices such as cardiac pacemaker

• Bladder stimulator

• Spinal cord stimulator

• Implants, areas where implants have been removed

• Damaged implants

• Metal inclusions near the treated area

• Pregnant women or possibilities to be pregnant

I understand all of these contraindications and have had consultation fully with the clinician

I would wish to be treated selected area as below

Abdomen

Back

Arm

Leg

Thigh

Bra Line

• I have been advised not to eat or drink two hours before and after the treatment.

• I understand that clinical results may vary depending on my response to treatment and my compliance with pre- and post-treatment instructions.

There are no refunds for services rendered.

Additional areas or machines will be extra charges

After I start my first session I cannot transfer this package or change the area.

I consent to clinical photographs being taken of my treated areas for my personal health record only

Must notify the clinician if my medical history changes prior to subsequent treatments

I understand that no guarantee has been given to me with regard to the percentage of improvement of my skin and that more than one treatment is recommended to achieve the desired results

I have read and understood this form and my questions have been addressed and answered to my satisfaction. I have fully understood the pre-treatment considerations and post-treatment instructions through consultation with a clinician and I will follow the recommendations.

Patient Name

Patient Signature

Date /Time

Parent or Guardian (if patient is minor)

Witness