VelaShape III is a new non-invasive treatment that uses a combination of technologies to contour your body and reduce the appearance of cellulite. Vacuum technology manipulates your skin while infrared light and bi-polar radio frequency energies gently heat fat cells and surrounding tissue.
Treatment with this device is contraindicated for patients with any of the following conditions:
*Although not recommended, these conditions may be treated at the discretion and under the full responsibility of the medical director/physician. In such a case, a small area should be treated and assessed a few days later to determine if the patient will tolerate the treatment without developing adverse effects.
Certain side effects may be experienced during treatment or shortly after. Although these side effects are rare and temporary, they should be reported immediately to a physician for proper treatment. These are the side effects that may appear in the treatment area:
I understand that the VelaShape is a device used for improving the appearance of cellulite and reducing circumferences and that it may also be therapeutic for improving circulation and muscle aches in the treated areas. I understand there is a possibility of short term effects such as discomfort, reddening, blistering, scabbing, temporary bruising and temporary discoloration of the skin, as well as rare side effects such as scarring and permanent discoloration. These effects have been fully explained to me client initials*. I have also been advised of the pre and post-treatment care which are as follows:
I understand that clinical results may vary depending on individual factors, including but not limited to medical history, skin type, patient compliance with pre and post-treatment instructions, and individual response to treatment.I understand that treatment with the Velashape involves a series of treatments and the fee structure has been fully explained to me client initials*. I certify that I have been fully informed of the nature and purpose of the procedure, expected outcomes and possible complications, and I understand that no guarantee can be given as to the final result obtained. I am fully aware that my condition is of cosmetic concern and that the decision to proceed is based solely on my expressed desire to do so. I confirm that I have informed the staff regarding any current or past medical condition, disease, or medication taken. I certify that I have been given the opportunity to ask questions & that I have read & fully understand the contents of this consent form. This consent form is valid until all or part is revoked by me in writing.I, full name*, authorize Anti-Aging Centers of Connecticut and it's designated staff to perform the Velashape treatment on my body.
I have received a copy of the Consent & Client Instructions
As part of your treatment, we will be photographing the treatment area of your body/face (and in some cases, filming the treatment process This will allow us to visually monitor your individual progress and see the results of your treatment over time. We would appreciate your willingness to share your outcomes and results with others, for both training and marketing purposes within the beauty, cosmetic and aesthetic industry. Your identity/personal information will not be revealed, if not preferred.
With this form I, full name*, give my full consent for all photographs/footage captured before, during and after my treatment at Anti-Aging Centers of Connecticut to be used for the following purpose (please initial the consent area below for each specified use):
I fully understand and agree to this consent form. I understand and agree that all photos will become the property of Anti-Aging Centers of Connecticut and will not be returned. I hereby irrevocably authorize the Anti-Aging Centers of Connecticut to edit, alter, copy, exhibit, publish, or distribute these photos for any lawful purpose. In addition, I waive any right to inspect or approve the finished product wherein my likeness appears. I also waive any right to royalties or other compensation arising or related to the use of the photo.
I hereby hold harmless, release, and forever discharge the Anti-Aging Centers of Connecticut from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization.
I have read and understand the above photo release. I affirm that I am at least 18 years of age, or if I am under 18 years of age, I have obtained the required consent of my parent/guardian as evident by their signature below:
We understand emergencies happen, and you may not always be able to call in advance. However, please know that when you "no show' or cancel an appointment within 24 hours, you are preventing other clients from receiving their services. In addition, our technician is left without a client to serve, and when this happens frequently, it hurts our whole AAC family.
If you need to adjust, reschedule or cancel your appointment, please call and leave us a voicemail if you do not speak directly with a staff member. This way, we will be able to continually adjust our schedule to best accommodate our clients, and we will have a record that you called outside of the 24 hour timeframe. We will always get back to you once we receive your message.
In the event that you 'no show' or cancel your appointment within 24 hours, we will charge the credit card on file a 'no show' fee in the amount of $25.00 if the appointment is scheduled for less than 60 minutes. If the appointment is scheduled for 60 minutes or more, you will be charged a $75.00 'no show' fee. If the credit card on file declines, the "no show' fee will be added to your account with us, and you will owe the amount to be paid in full at your next scheduled appointment.
AAC is an in-demand, busy medical spa. Please note that canceling or rescheduling appointments with short notice may result in longer waiting times for appointments, and AAC cannot guarantee you will be able to stay on your recommended treatment plan schedule.
At AAC, we do require that a credit card or debit card is kept on file as a convenient method of payment, in the event of a "no show' or late cancellation (within 24 hours of scheduled appointment time Our credit card information is kept
By signing below, I authorize AAC (Anti-Aging Centers of CT) to charge a no show fee to my credit or debit card on file, in accordance with all of the above information if I "no show' or cancel an appointment within 24 hours. I, the undersigned, recognize that it is my financial responsibility to pay any incurring fees in accordance with this policy.