Body Contour Vacuum Therapy Consent Form
Please complete this form to provide your consent and share relevant health information before your body contour vacuum therapy session.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Appointment Date and Time
*
Have you experienced any of the following conditions? (Please select all that apply)
*
Pregnancy or breastfeeding
Heart conditions or pacemaker
Skin infections or open wounds
Recent surgery in the treatment area
None of the above
Other
Please share any additional medical conditions, allergies, or concerns we should be aware of:
Signature (Please sign below to confirm your consent)
*
Submit Consent
Submit Consent
Should be Empty: