Please, print, sign and bring to your first appointment.
LIPO LASER CLIENT CONSENT FORM
Name:____________________________________________________________________________________________ Address/Province/City/Postal Code:__________________________________________________________________ Email:______________________________________________ Age: _______ Phone #:__________________________ Voucher number________________________________Barcode____________________________________________
The Lapex BCS is a new and innovative technology that has been approved spot fat reduction and body contouring in Canada
The Lapex BCS is one of the tools that we can use to help you reach your goals and the real advantage of this technology lies in the fact that we can specifically target a trouble area. Once the fats have been released from the cell they can be used by the body as a fuel source. It is therefore critical that the dietary and lifestyle changes are made to help support the goals of treatment.
A reduced calorie diet and an exercise program that will help to burn approximately 350 – 500 calories post treatment are ideal. Individual results may vary and it is the responsibility of the client to ensure they are doing the appropriate home care to ensure maximum results. Clients should be consuming a caloric intake equivalent to their target weight (lbs) multiplied by 10. For example a 220lb male who wants to reach 200 lbs should be consuming a daily intake of 2000 calories. In some cases additional support may be required for lymphatic drainage to help stimulate the body to clear the fats that are released from the cell. Most clients experience a 1⁄2 inch reduction with each treatment and multiple inches can be lost with a series of treatments. Ensure Your Best Results :
Avoid consuming large amounts of water prior to treatment(s)
Don’t eat 4 hours prior to treatment(s)
Drink plenty of water after every treatment
Incorporate Whole Body Vibration (WBV) post treatment for 10 minutes or
Ensure you undertake physical activity following each treatment to maximize your results Manage caloric intake; excess calories will counteract the laser treatments
Alcoholic beverages and high sugar content drinks must be avoided before and after treatment(s)
I, _______________________________, in signing this agreement understand that I am beginning a series of treatments to help reach my goals of body contouring and spot fat reduction. I understand that individual results may vary and that I must commit to changing the dietary and lifestyle factors necessary to achieve optimal results. I understand that the first step to a positive change is creating awareness about the steps necessary to reach these goals, and will work diligently to ensure success.
I understand that much of the success of the program will depend on my efforts and that there are no guarantees or assurances that the program will be successful. I realize there may be pre-existing medical conditions that can preclude me from seeing optimal results. By signing this agreement I release the 0582551 BC LTD DBA IRIS BEAUTY SOLUTION, manufacturer and distributors from any liability regarding this treatment and do so understanding that results can vary from one individual to the next.
I have read and fully understand this consent form and I realize I should not sign this form if all items have not been explained to
me. My questions have been answered to my complete satisfaction. I have been urged and have been given all the time I need to read and understand this form.
If you have any questions regarding the risks or hazards of the proposed treatment, or any questions whatsoever concerning the proposed treatment or other possible treatments, ask your technician now before signing this consent form.
I confirm the following:
I am over the age of 18
I have no known liver or kidney disorders
I am not pregnant or lactating
I have no know thyroid gland dysfunctions
I do not have epilepsy
I do not have a compromised immune system
I do not have a pacemaker
I do not have cancer or a history of cancer
I do not have Herpes Simplex
I have no known photosensitivity to sun exposure
I do not have uncontrolled Hypertension
I am not taking drugs that cause photosensitivity
I consent to taking photographs and authorize their anonymous use for the purpose of medical audit, education, and / or promotion _______ (clients initial)
Limitation to Agreement
I understand there are no guarantees as to the results of this treatment.
I understand that to achieve maximum results, I may require several treatments.
It has also been recommended to achieve optimum results, I understand that an appropriate diet and regular exercise
will assist to sustain and create acumulative degree of overall spot fat reduction and body contouring.
I have been informed and I understand that temporary hyperpigmentation / hypopigmentation on rare occasion may occur as a result of treatment.
I herby certify that all information that I have provided has been accurate and truthful.
I herby authorize 0582551 BC LTD DBA IRIS BEAUTY SOLUTION to perform the LAPEX BCS procedure for the purpose of aesthetic body contouring and girth loss.
CLIENT signature ____________________________ Date___________________________________