Cavi/RF Body Sculpting Consultation Form

Do you have any of the following?

Heart Conditions inc. Pacemaker

Scarring history, fibrosis or seborrhoea

Silicosis or other Lung Conditions

Haemophilia or other clotting disorders

Cancer (Radiotherapy/Chemotherapy)

Reynaud’s Disease (or other vaso constrictive YES disorders)

Other immune disorders not listed

Immune System Disease (i.e. AIDS or HIV)

Received or donated organ transplants

Urticarial or other immune disorders

Psoriasis or eczema in treatment area

Keloid/hypertrophic scar in the region

Hernia or weak stomach muscle walls

Undiagnosed swelling or inflammation

Metal Plates or Joint Implants

Sites of prior cosmetic surgery

Any other conditions not listed

Currently under the influence of drugs or alcohol

If you have answered yes to any of the above, please give full details:

Are you currently taking any medication?

If yes, please list all medications

How is your sleep pattern? Good Average Poor

How is your diet? Good Average Poor

How much water do you drink per day?

If yes, how many units per week?

If yes, how many cigarettes per day?

How often do you exercise per week?

Have you ever had body contouring, fat removal or similar treatments before? If yes, please give details below including the type of treatment and the area.

Are you fully committed to making the relevant changes to get the best possible results from your treatment?

Informed client consent to body sculpting treatment

of Cavitation/Radio Frequency treatments as discussed and agreed.

consent to, and authorise, the Qualified Practitioners (clinic name) to carry out Ultrasound

• The areas to be treated are:
• The treatment has been fully explained to me. I understand that this treatment will take several sessions and a course of treatments is recommended for best results.

depend on how well I follow my aftercare advice.

lots of water, regular body brushing, following a healthy diet and partaking in regular

Whilst I understand that the results from the treatments vary considerably, I

reddening, bruising, tenderness. I accept these risks are possible and do not hold the

therapist or company responsible for any adverse reactions that may occur from treatment.

with the explanation and information given to me regarding the possible side effects

and outcome of Ultrasound Cavitation and/or Radio Frequency.

follow these guidelines at all times during the treatment programme.

hours and, in the cases of ore serious side effects, will contact my GP to obtain medical

• advice.