READ CAREFULLY – INFORMED CONSENT TO TREATMENT

Ultrasound Cavitation Treatment Agreement

Name: Email Address: DOB:

Address: City: State: Zip:

Phone: (work) (home) (cell)

Emergency Contact: (name) (phone)

Ultrasound Cavitation Treatments Check all that apply:

____ Abdomen ____ Upper Legs “Saddle Bags” ____ Lower Legs (Hamstring Area)

____ Inner Thigh ____ Arms (tricep side) ____ Back

____ Buttocks ____ Calf ____ Flanks “Love Handles”

Fees. All costs are payable in-full prior to initial treatment and are non-refundable. Payments must be completed for entire package

price (1, 3, 6, 9 or 12 sessions) on first visit to receive package discount. Packages once purchased and treatment initiated are nonrefundable.

Medical Background. Check if you answer YES to any of these questions:

o Are you pregnant or nursing?

o Are you epileptic?

o Do you have any kind of tumor or cancer?

o Do you have any cardiac or vascular disease or condition?

o Do you have any acute inflammation?

o Do you have a wound that has not healed?

o Do you have current or any history of internal bleeding?

o Do you have a pacemaker or other electronic device?

o Do you have any plastic or bone cement or any large metal

implant? WHERE?_______________

o Have you had any abdomen operations?

o Do you have any abnormally high or low blood pressure?

o Do you have high levels of Triglycerides (hereditary)?

o Do you have hemophilia?

o Do you have melanoma?

o Do you have thrombosis and / or thrombophlebitis?

o Have you undergone a transplant?

o Do you have a Neurological disorder?

o Are you being treated with anticoagulants?

o Do you have any keloid?

o Do you have any kind of heart trouble?

o Do you have any current infection?

o Do you have any infectious disease or tuberculosis?

o Do you have advanced untreated diabetes?

o Do you have a communicable disease?

o Do you have any type of heart, kidney, liver

disease?

IF YOU ANSWERED “YES” TO ANY OF THESE

QUESTIONS YOU MAY NOT BE ELIGIBLE FOR

THE TREATMENT. Explain any Yes answers:

_____________________________________________

Are you presently taking any medications? List:

Are you allergic to any foods or medication? List:

Please explain any other current medical conditions.

Are you taking any vitamins/supplements?:___________________________________________________________

Are you presently under a physician’s care? What for?

Are you taking recreational drugs?

Please list your family or primary treating physician name and phone number:

____________________________________________________________________________________________