Medical History Form
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Emergency Contact
Medical Background
IF YOU ANSWERED "YES" TO ANY OF THESE QUESTIONS YOU MAY NOT BE ELIGIBLE FOR THE TREATMENT.
Informed Consent for Body Sculpting Services
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Brief Description of Treatment
Body sculpting are typically a series of 9-12 treatments per area, but some individuals may require more treatments to achieve maximum results. There should be at least 3 days between each treatment. Mesolipo Fat Dissolve treamtments require at least 7 days between each treatment. A combination of the following services and products may be used during your treatment depending on the specific needs for each individual and we be determined on a case-by-case basis:
Lipo Skinny Shots (Mesolipo Fat Dissolve) Package | Lipo 360 Package | Post Surgical Drain & Suture Removal by a Nurse | Post Op Manual Lymphatic Drainage | Laser Lipo Treatment with Full Body Vibration and Consultation | Colombian Wood Therapy | Body of a Goddess Bundle | Botox | Dermal Fillers | IV Hydration | Wellness Shots | Instant Liquid BBL
Ointments | Creams | Oils | Feminine Care | Shapewear | Detox Products
Body sculpting is used to increase the flow of both the lymphatic and circulatory systems, and it also helps with the cleaning of the tissues. The main use of body sculpting treatments is inch loss, diminishment of cellulite, and tightening of the skin. Benefits are often visible immediately after treatment but may be delayed in some people. This is not a weight-loss treatment, but an inch loss treatment. The inches will only return if the client has poor eating habits, does not exercise regularly, or is not drinking the recommended 8glasses of water per day. For best results, it is recommended that you exercise within 4-6 hours of treatment and avoid sugar for 24 hours after each treatment.
Potential Risks and Complications
I understand that all treatments carry certain risks. The potential risks and complications from the treatment are: • Redness• Bruising• Swelling• Irritation• Adverse skin reactions• Increased heart rate
Body sculpting treatments are not recommended if you are pregnant, breastfeeding, have a lymphatic disorder, acute illness, metal implants, pacemakers, or are currently being treated for active cancer. The Ultrasound Cavitation treatment includes, but is not limited to, the use of high-power, low frequency ultrasound cavitation which uses 40KHZ – 80KHZ frequency ultrasound to penetrate the skin and assist with the breakdown of fat cells by creating microtubes that increase the pressure around the adipocyte and forcing it to implode, thus breaking down the adipocyte’s cell membrane. Therefore, the Ultrasound Cavitation treatment carries with it possible health complications and consequences, which include and are not limited to the risk of kidney failure, liver failure, pacemaker failure, birth defects, miscarriage, thyroid damage, damage of the ovaries, lactation complications, hypertriglyceridemia, hypercholesterolemia, pancreatitis, infection, scarring, and/or allergic reaction to any products used, excessive thirst, dehydration,and nausea.
Disclosure – READ CAREFULLY, THIS AFFECTS YOUR LEGAL RIGHTS
This treatment is a process and subsequent visits may be necessary in order to achieve the desired results. Subsequent visits are subject to additional charges per visit, which depend on the amount of work needed. Actual results may vary from person to person and Goddess Aesthetics Wellness LLC does not guarantee any specific result. After care instructions must be followed explicitly, whether given in writing or orally. Failure to follow after care instructions may compromise the final results of the treatment.
I have been explained the implications of not undergoing this treatment and the alternative methods of treatments such as other sculpting treatments, fat freezing treatments, liposuction surgery, fat dissolving injections, etc.
I am now aware of the intended benefits, possible risks and complications, and availablealternatives to this treatment. I am also aware that results of any treatment can vary from client to client, and I declare that no guarantees have been made to me regarding success of this treatment. I am aware that while majority of clients have an uneventful treatment, few cases may be associated with complications. I am aware of the common risks and complications associated with this treatment and understand that it is not possible to list all possible risks and complications of any treatment.
I understand that Ultrasound Cavitation and other body sculpting treatments are not a substitute for healthy lifestyle choices, such as healthy eating habits and exercise. I further understand and acknowledge that there is no such thing as a “magic” cure for obesity. I understand that the final result of any weight loss effort is profoundly improved with the inclusion of physical activity, increased water intake, and lymphatic drainage. Failure to improve my dietary and lifestyle habits will result in future weight gain and a potential need for additional treatments, even after a successful series of initial treatments. I have been advised to refrain from purchasing treatment packages until after I have experienced satisfactory results and I am certain that I want to continue treatment.
I also understand that sometimes a planned treatment may need to be postponed or cancelled if clients clinical condition demands or due to any unforeseen technical reason. I am also aware that I can withdraw my consent at any point in time at my own risk and consequences, by submitting a notice of withdrawal in writing.
I understand that if medical exigencies demand, further or alternative treatment measures may need to be carried out and, in such case, there may be difference in the planned and actual treatment.
I agree to observing, photography (still/video/televising) of the treatment for academic/promotional purposes. I also understand and agree that any recordings made during the class can be edited and used on any Web or social media platforms.
I am also aware of the expected course after the treatment and the post-treatment care to be taken.
I am going to pay on a per session/package basis. Package basis, if opted for, includes minimum number of sessions and I have to pay accordingly if any additional sessions or treatments are required.
I understand that I must reschedule or cancel my appointments 24 hours prior to the start time of the appointment. Any cancellations within 24 hours of my appointment start time or no-shows will automatically forfeit deposit and will not be rescheduled. All costs are payable in full prior to the initial treatment, unless otherwise agreed upon, and are non-refundable. Costs do not include future visits unless otherwise expressed.
I understand that if I am late, any time lost will be taken out of my session time and will notaffect my next session.
I recognize that there are certain inherent risks associated with the above-described treatments and I assume full responsibility for personal injury to myself. I attest that I am a healthy, qualified candidate for such treatment to the best of my knowledge. In exchange for such treatment, I hereby fully release and forever discharge Goddess Aesthetics Wellness LLC (including its officers members, owners, employees, and agents) from any and all damages, costs, expenses, liabilities, causes of action, claims and demands, of whatever character, in law or in equity, whether known or unknown, direct or indirect, asserted or unasserted, and whether or not on account of myself, Goddess Aesthetics Wellness LLC , other third parties, or in any way arising out of the above-described treatment I have requested Goddess Aesthetics Wellness LLC to perform. I agree to indemnify, hold harmless and defend Goddess Aesthetics Wellness LLC (including its officers, members, owners, employees, and agents) against all third-party claims, causes of action, damages, judgments, costs or expenses, including attorneys’ fees and other litigation costs, which may in any way arise from the above-described treatment I have requested Goddess Aesthetics Wellness LLC to perform.
It is understood that any dispute arising to malpractice of the Ultrasound Cavitation treatment or other body sculpting treatments shall be decided by a neutral arbitrator. Any arbitration proceeding will be governed by Texas’ arbitration statute, the fees for the arbitrator will be split pro-rata among parties and each party will be responsible for their own attorneys’ fees and costs. Any action to collect fees from the client/patient for the treatments performed may be brought in any court located in Illinois and the prevailing party in such collection action shall been titled to recover its reasonable attorneys’ fees and costs. Filing of any action in any court to collect any fee from the client/patient shall not waive the right to compel arbitration of any malpractice claim. By signing this agreement, I confirm that I am over the age of 18, I understand that the Ultrasound Cavitation procedure is permanent, that such procedure has possible adverse consequences, and that the procedure is for cosmetic purposes only. This means that I accept full responsibility for these and/or any other complications, which may arise or result during or following the above-described treatments, and I hereby agree to arbitration of any malpractice claim.
I declare that I have received and fully understand the information provided in this consent form, that I have been given an opportunity to ask questions related to my treatment, the treatments being performed, its risks, consequences, alternatives, potential complications, and the intended benefits and recovery. I declare that all my questions have been answered to my complete satisfaction and there are no misconceptions or false hopes in my mind. I further declare that all fields (of this form) requiring insertion or completion were filled in my presence at the time of my signing this form.
For the above-mentioned treatment(s) that I have been made aware of, I give my consent voluntarily to
for carrying out the said treatments on myself, being fully aware of the nature, potential risks complications, intended benefits and possible alternatives.
I, the above-named client, do further hereby declare that I am above 18 years of age on the date of signing this form, mentally sound, and am giving consent without any fear, threat, or false misconception.
