Below is the consent I send to every client after he or she books an appointment. This MUST BE signed before this procedure is performed:

ULTRASONIC CAVITATION PATIENT CONSENT

Ultrasonic Cavitation is a technology that breakdowns fat deposits, which can be performed mid and lower abdomen, upper, mid, and lower back, thighs and calf areas, hip and buttocks area, arms, and chin. These procedures do not involve invasive surgery - there is no need for anesthesia, hospital stay and no down time. They provide a non-invasive method to break down stubborn fat deposits that never seem to disappear no matter what your diet is or how hard you exercise.

Appointments are can be scheduled every 3 days, but not sooner. In order to ensure maximum results, it is necessary to follow the recommended treatment schedule. The total number of treatments will vary between individuals. On occasion, there are patients that do not respond to treatments. I understand the nature, goals, limitations and possible complications of this procedure and have discussed alternative forms of treatment. I have had the opportunity to ask questions about the procedure, as well as any limitations, complications and/or side effects.

I have read, agree to, and understand the following:

•        The goal of any treatment, as in any cosmetic procedure, is improvement, not perfection, and results may not be perfect due to any genetic, hormonal, nutritional, or topical applications interference or an impact of unpredictable reactions.

•        Individuals with a past history of herpes simplex virus infections and individuals with no known history of herpes simplex virus infections. Bacterial, fungal and viral infections can occur. Herpes simplex (viral infections) around the mouth can occur following a treatment. Should any type of skin infection occur, check with your physician for proper treatment.

·         Allergic Reactions: In rare cases, allergies to tape, preservatives used in cosmetics, topical preparations, etc. have been reported. Systemic reactions (which are more serious) may result from prescription medicines.

·         Compliance with the aftercare guidelines is crucial.

·         Occasionally, unforeseen mechanical problems may occur and your appointment will need to be rescheduled. We will make every effort to notify you prior to your arrival to the office. Please be understanding if we cause you any inconvenience.

Do not accept advice from anyone not directly responsible for your post care. Suggestions from friends may be sincere, but are often not helpful or even innocently harmful.

PRE and Post Care:

•        For 24 hours before and 72 hours after treatment client must refrain from consuming fried foods, processed and refined foods, sugar, carbohydrates, unhealthy fats, and alcohol.

•        It is also helpful if the client does some type of light exercise within 24 hours after treatment to prevent reabsorption, however it is not required.

•        Lightly massage treated area after treatment

•        Drink lots of water

•        Wearing a compression garment is also recommended

ACKNOWLEDGEMENT

I have read and understand all of the above. I have asked any and all questions that I have regarding the procedure of laser lipo/ultrasonic cavitation, pre-treatment and post-treatment. I was given written instructions for post-treatment care at home. I understand completely and will take full responsibility for post-treatment care. All of the treatment fees have been discussed with me and I understand them completely. My questions regarding the procedure have been answered satisfactorily. I understand the procedure and accept the risks. I hereby release all related staff from all liabilities associated with the above-indicated procedure. By signing this form, I am giving FaithFULL Brows permission to treat me, and I understand all symptoms and side effects that may occur during or after treatments, thereby releasing FaithFULL Brows of all liability regarding these issues.

Should you have any concerns or questions, please do not hesitate to call FaithFULL Brows. My main goal is client satisfaction. That is why it is VERY important to educate my clients so they will fully understand the procedures of Ultrasonic cavitation and have trust, confidence and cooperation in their decision.

We provide each client with full consultation, before treatment, and information of pre and post care necessary to achieve the best results possible. All clients MUST sign this Consent Form indicating that they have read all of the pre and post-treatment instructions, which are also on the company website and discussed during consultation. The consent form is an agreement with the client that he/she is agreeing to be treated and that the client fully understands all pre- and post-treatment instructions as well as possible symptoms and/or side effects and skin reactions that may occur due to treatment. These symptoms and side effects include: diarrhea, headaches, toothaches if client has metal teeth fillings, bruising, ringing in the ears, kidney failure, liver failure (e.g. fatty infiltration of the liver), carrying a pacemaker or other electronic devices, pregnancy, lactation, hypertriglyceridemia, or hypercholesterolemia. These symptoms and side effects are normal and cannot be predicted. All side effects vary with each individual.

I understand that FaithFULL Brows will not provide Lipo Cavitation to those with the following conditions:

•        Pregnant women or women currently on their cycle

•        Epileptic

•        Cancer patients

•        Patients whose wounds after operations have not healed

•        Acute inflammation epidemical patients

•        Heart disease or with heart pacemaker

•        Kidney disease

•        Metal implant or silica gel implant

•        Plastic surgery or surgery to the belly (has to be at least 4 months with Dr approval)

•        Natural elevated body temperature

•        Genetic hypersensitivity

If I mislead the physician, technician or student for any of the reasons mentioned above, by signing below I fully understand and take responsibility for the post-treatment consequences.

Occasionally, unforeseen mechanical problems may occur and your appointment will need to be rescheduled. I will make every effort to notify you prior to your arrival to the office. Please be understanding if I cause you any inconvenience.

Should you have any concerns or questions, please do not hesitate to call FaithFULL Brows. My main goal is client satisfaction. That is why it is VERY important to educate clients so they will fully understand the procedures of skin resurfacing and have trust, confidence and cooperation in their decision.

Initial Please

______ I consent to the taking of photographs during the course of my laser therapy for healthcare records.

______ I consent to using my photographs for medical education and/or marketing purposes. My name will not be used to identify these photographs.

______ I am not pregnant or nursing.

______ I have been given the opportunity to ask questions about the procedure. My questions have been answered and I understand the information given to me.

______ Contraindications to the performance of this procedure have been discussed in detail with me. ______ I recognize that the practice of medicine is not an exact science and acknowledge that no guarantees have been made to me concerning the results of such procedures.

______I have read and understood all information presented to me before signing this consent form. ______ I hereby release all related staff from all liabilities associated with the above indicated procedure.

______ By signing this form, I am giving FaithFULL Brows permission to treat me, and I understand all symptoms and side effects that may occur during or after treatments, thereby releasing FaithFULL Brows of any liability regarding these issues.

______ 24 HOURS CANCELLATION POLICY Confirmation of your appointments is a courtesy call not an obligation. It is the client’s full responsibility to keep track of his/her scheduled appointments. If client fails to notify of appointment cancellation at least 24 hours in advance, the no-show will be counted as used treatment of the client’s package deal or $50.00 fees must be paid to accommodate the licensed technician time.

______ PACKAGE REFUND POLICY. By signing this No Refund Policy, I am agreeing that any service(s), service package(s), gift certificate(s), and/or retail product I purchase(s) at FaithFULL Brows is a final sale and packaged services will be completed within 3 months of the initial appointment.  I understand any and all services(s), service package(s), gift certificate(s), and/or retail product(s) purchased will not be refunded or issued a credit. I also understand that if I decide to cancel or postpone any service(s), service package(s), gift certificate(s), and/or retail product(s), I will forfeit all monies paid; including any deposits and/or payments I have already paid. I acknowledge being given a copy of this Agreement at the time it was signed.