• Understand all post treatment recommendations and agree to adhere... them • Freely assume any risks of complications or injury from...

Client Intake Form – Lipo Laser
Personal Information:
Name________________________________________________
Address______________________________________________
City / State / Zip _______________________________________
Phone _______________________
DOB _________________
Email ________________________________________________
Date of Initial Visit ____________________
How did you hear about us? ______________________________
Are you now taking or have you recently taken any medication that has
caused a photosensitive or photo allergic reaction? Yes No
If yes, ________________________________________
Ensure Your Best Results
• Drink plenty of water after every treatment
• Ensure you undertake physical activity following each treatment to
maximize your results
• Manage calorie intake; excess calories will counteract the Laser
Treatment
• Alcoholic beverages and high sugar content drinks must be avoided
Procedure
Laser paddles will be placed on the exposed area(s) to be treated. It is
recommended that a client receive at least 6 treatments over a 45 day
period to achieve the maximum potential effect. This treatment should be
used in conjunction with a healthy diet and exercise.
Risks/Discomfort
• Understand all post treatment recommendations and agree to adhere to
them
• Freely assume any risks of complications or injury from known or
unknown causes associated with, relating to, or otherwise arising out
of this procedure
• Have the right to consent to or refuse any proposed procedure at any
time prior to its performance
• Have a tattoo in the treatment area that is new or not put on deep
enough, that there is a slight risk the area may bleed or blister
• Must notify the clinician if my medical history changes prior to
subsequent treatments
• Release Ionique Wellness Spa LLC from liability associated with this
procedure.
___________Initial
It is important to know, 100% certainty of success cannot be assured as
with any medical procedure. In some cases results may vary and
therefore may not always meet expectations of all patients completing a
full series of treatments.
I have reviewed this consent form. My consent and authorization for this
procedure are strictly voluntary. By signing this form I grant authority for
Ionique Wellness Spa LLC to perform the described treatment.
The purpose of this procedure, risks, complications, alternative methods
of treatment have been fully explained to my satisfaction. I have been
informed of the potential risks and side effects of Laser Lipo including but
not limited to redness, swelling, heat sensitivity, pain and flu like
symptoms. Increased bowel movements, urination, and menstrual flow
are possible. The nature of the proposed procedure, risks, potential
damages and adverse side effects have been explained to me and I fully
understand.
___________Initial
I understand that a minimum of 6 treatments is required to achieve full
results. At that point I will be reevaluated to see if more sessions are
needed in order to achieve realistic goals. Clients who are extremely thin
may require fewer treatments, while heavier clients may require more. I
understand the treatment is most successful if I also maintain a healthy
diet and commit to an exercise program. I know that if after the treatment
course I gain weight, the results of the Laser Lipo may be reversed.
There are few risks associated with laser therapy. This treatment is
non-­‐invasive and uses a cold output laser. During treatment no
discomfort will be present, the client will not feel the laser, however the
light will be visible. Although no known detrimental risks exist, potential
unknown risks may exist. If you are pregnant or you have a pacemaker,
this treatment is not for you.
___________Initial
My signature and initials in the next column constitutes my
acknowledgment that I’m a competent, consenting adult of at least 18
years of age (or my parent or legal guardian is giving consent on my
behalf), and further, that I:
I have read and understand all the terms and conditions stated above.
No refunds will be given for treatments received.
• Have read and understand the information provided in this form
• Have had my procedure adequately explained to me by my clinician
• Have had the opportunity to ask questions, and all of my questions
have been answered to my satisfaction
• Have received all of the information I desire concerning my procedure
(Printed name of Signatory) _________________________________
I, ____________________________consent to, and authorize Ionique
Wellness Spa LLC to perform laser treatment for body contouring and I
agree to comply with the recommendations for optimal results.
Signature Patient ______________________________________
Date: ___________