Body Contouring Consultation/Consent Form | Aesthetics Forms Portal

Body Contouring Consultation and Consent Form

Client Details

Full Name: *

Date of Birth: *

Contact Number: *

Have you recently been unwell? *

Which of the following were you unwell with? *

Please provide more detail: *

Do you have any medical conditions? *

Please list: *

Are you currently taking any medications? *

Please list: *

Do you have any allergies? *

Please list: *

Emergency Contact Details

Emergency Contact Name: *

Emergency Contact Relationship: *

Emergency Contact Phone: *

BMI

Body Mass (kg): *

Height (metres): *

BMI:

Category:

Treatment Information

Nonsurgical body contouring is also known as nonsurgical fat reduction. There are a variety of nonsurgical fat reduction procedures. These procedures reduce or remove stubborn pockets of fat to contour and shape different areas of the body. Most nonsurgical fat reduction treatments are based on one of these four principles:

1. Cryolipolysis, or controlled cooling, uses freezing temperatures to target and destroy fat cells.
2. Laser lipolysis uses controlled heating and laser energy to target fat cells.
3. Radiofrequency lipolysis uses controlled heating and ultrasound technology to target fat cells.
4. Injection lipolysis uses injectable deoxycholic acid to target fat cells.

Nonsurgical body contouring procedures are NOT intended to be weight loss solutions. Ideal candidates are close to their desired weight and want to eliminate stubborn pockets of fat that are resistant to diet and exercise. With most body contouring procedures, your body mass index shouldn’t be over 30.

Treatment

1. Where do you want to reshape your body? *

Abdomen Thighs Flank Arms Underneath the buttocks Back Chin Other

If Other, please specify:

2. Are you generally at or near your ideal body weight but have areas of excess fat? If you don’t know your ideal weight, please answer “Not Sure”. *

3. Please list your goals and timeline: *

Pregnancy / Breastfeeding

1. Are you currently (or possibly may be) pregnant? *

2. Have you given birth within the last three months? *

3. Have you breastfed within the last three months? *

Health Information

1. Have you ever had a medical aesthetic procedure to improve your appearance? For example, Have you ever had laser treatments, facial injections, or body enhancements? *

Please specify: *

2. Do you have any tattoos or significant moles on the area to be treated? *

3. Do you have any Scarring, hernias, or skin disorders in the area to be treated? *

4. Do you suffer from Heart disease? *

5. Do you suffer from High cholesterol? *

6. Do you have a Pacemaker fitted? *

7. Do you have any Liver or pancreatic conditions? *

8. Do you take any Anticoagulant drugs (e.g. Warfarin, Aspirin)? *

9. Do you suffer from Haemophilia (blood coagulation disorder)? *

10. Are you HIV positive? *

11. Are you exposed to Organophosphates, herbicides or pesticides? *

Pre and Post Treatment Advice

Please take a moment to read the pre-treatment and aftercare advice.

- Drink 10 or more cups of water on the day of your treatment, and for the following 3 days. This helps your body process the fat and speeds up your metabolism.
- Do not drink alcohol on the day of your treatment, and for the following 3 days. If possible eliminate alcohol completely as alcohol contains excess sugar which can cause weight gain and slows down your liver function, which is imperative to your results.
- Do have a healthy diet; eliminate sugars and refined carbohydrates such as white bread, white pasta, white rice and sugar.
- Avoid soda pop and sugary drinks and also fast food, fried foods, excess oil and butter.
- Maintain a healthy diet, which consists of lean proteins and vegetables.
- Walking and/or exercise will help shed fat and speed up your metabolism.

Please tick the box to confirm: *

I have read and understood the aftercare advice given to me on this form.

Consent

I accept that any treatment I am going to receive is at my own risk.
I certify that I have read, fully understood, and completed this form to the best of my knowledge.
I understand that failure to disclose information requested above may result in adverse side effect(s), unknown because of this to which I accept full liability/responsibility.
The treatment(s) and possible side effect(s) have been fully explained to me.
I accept full responsibility for the treatment given and complications which may arise or result during or following any procedure that is performed at my request.
I accept that if I am not satisfied with the treatment I will inform the therapist and/or request to speak to the manager during, or immediately following, the treatment.
I fully understand the above and consent to the Body Contouring treatment(s) to be carried out.

Signature: *

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