Consent to Treat
Consent to Treat
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
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
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: