Treatment Consent Form - Cavi Lipo
I duly authorize the Doctors & Technicians of Rejuvenations Incorporated to perform the procedures for the purpose of body contouring, lymphatic drainage, improving the appearance of cellulite, and skin tightening. I am aware that the clinical results may vary depending on the individual factors, including, medical history, patient compliance with pre/post treatment instructions, and individual response to treatment. I have been made aware that my diet and the amount of exercise I do with have a major effect on the results of my treatments. If I do not make the effort to address my diet and exercise, I am aware that the results achieved may not be retained.
I understand that the treatment by Rejuvenations Incorporated involves a course of treatments. The fee structure has been fully explained and I understand that I am required to pay for the course of treatments prior to any procedures taking place. I am fully aware that should I wish to cancel the course of treatments, that the value of the outstanding / remaining treatments is non-refundable.
Due to demand for treatments, we schedule all appointments following the initial consultation. Please be aware that all cancellations require a minimum of 24 hours notice. Failure to do so will result in that treatment being deducted from the course of treatments remaining without a refund. It is important to be aware that this may have a negative effect on your overall results. Any change to the initial treatment dates will be subject to availability. If you are more than 5 minutes late, we may not be able to accommodate your treatment appointment, as this may inconvenience other clients. Rejuvenations Incorporated reserves the right to deduct a treatment from your treatment course without refund.
I certify that I have been fully informed of the nature and purpose of the Cavi-Lipo procedure, expected outcomes, and possible complications. I understand that no guarantee can be given as to the final result obtained. I am fully aware that my condition is of a cosmetic concern and that the decision to proceed is based solely on my expressed desire to do so.
I understand that it is my personal responsibility to inform the Doctor or Therapist of any changes to my medical history during the course of treatment sessions and I confirm that should this occur, I shall advise the Doctor or Therapist of any changes.
Photo/Video Release:
I consent to the taking of Photographs and or Video /Video Testimonials and authorize their anonymous use for the purpose of medical audit, education, and promotion. [Delete if preferred]
I certify that I have been given the opportunity to ask questions and that I have read and fully understand the contents of this Consent Form.