LASER LIPOLYSIS CONSENT FORM

PATIENT INFORMATION:

First Name

Last Name

Date Of Birth

Phone/Mobile

City

Next Of Kin

Kins Contact Number (Phone/Mobile)

MEDICAL HISTORY

Do you have any implanted medical devices (e.g., pacemaker, metal implants, or electronic devices) in or near the treatment area?

Yes

If Yes, please specify:

Do you have any liver, kidney, or lymphatic system conditions that may affect fat metabolism or elimination?

Yes

If Yes, please specify:

Do you have any skin conditions, infections, sensitivity, or open wounds in the treatment area?

Yes

If Yes, please specify:

Are you currently taking medications or supplements that may affect circulation, metabolism, or fluid retention (e.g., blood thinners, diuretics)?

Yes

If Yes, please specify:

Are you currently pregnant, trying to conceive, or breastfeeding?

Yes

If Yes, please specify:

Do you have any other medical conditions?

Yes

If Yes, please specify:

Procedure Description:

I understand that I am receiving a laser lipolysis body contouring treatment, which is a non-invasive procedure designed to target and reduce localized fat deposits while supporting body contouring and inch loss.

Laser lipolysis uses low-level laser energy to penetrate the skin and target fat cells beneath the surface. This process stimulates the fat cells to release stored fatty acids, glycerol, and water, effectively shrinking the fat cells. The released contents are then naturally processed and eliminated by the body through the lymphatic system.

During the procedure, specialized laser pads will be applied to the targeted areas of the body and secured in place. The device emits controlled laser energy into the treatment area while remaining safe and comfortable for surrounding tissues.

The treatment is generally painless and relaxing. I may experience a gentle warming sensation in the treated area, but discomfort is minimal. Sessions typically last a set period during which I will remain still while the treatment is in progress.

I understand that multiple sessions may be required to achieve optimal results, and that outcomes vary depending on individual body composition, lifestyle, hydration, and adherence to aftercare recommendations.

Benefits and Risks

I have been informed that the potential benefits of laser lipolysis treatment may include:

Reduction in the size of localized fat deposits
Improved body contour and inch loss in targeted areas
Non-invasive fat reduction with no downtime
Support for lymphatic drainage and fat metabolism
Targeting of stubborn fat areas resistant to diet and exercise
Comfortable and pain-free treatment experience

I understand that there are potential risks and side effects associated with this treatment, including:

Mild warmth or tingling sensation during the procedure
Temporary redness or sensitivity in the treated area
Increased urination as the body processes and eliminates released fat contents
Mild fatigue or lightheadedness in some cases after treatment
Uneven or gradual results requiring multiple sessions for desired outcome

I understand that serious complications are uncommon but may occur in rare cases.

Aftercare:

I agree to follow the post-treatment instructions provided by the clinician to ensure the best possible results and minimize any risks. I understand that failure to adhere to these instructions may increase the likelihood of complications.

Consent for Treatment:

I hereby consent to undergo an Laser Lipolysis treatment. I acknowledge that the clinician has explained the procedure, its benefits, and potential risks to me. I have had the opportunity to ask questions, and all of my concerns have been addressed to my satisfaction. I understand that the results of an Laser Lipolysis treatment can vary, and multiple sessions may be required for optimal results.

Release of Liability:

I release The Abram, its employees, and representatives from any liability associated with the Laser Lipolysis treatment, except for cases of negligence or intentional misconduct.

Human Error Acknowledgment:

I understand that aesthetic treatments are performed by qualified clinicians using professional equipment and established protocols. However, I acknowledge that, as with any procedure involving human involvement, there is a possibility of unintended outcomes due to human or technical error. By signing this consent, I accept this inherent possibility and agree that The Abram and its staff shall not be held liable for minor or unintentional errors occurring during the course of treatment, provided that reasonable care and professional standards are followed.

Photographs and records:

I understand that videos and photos will be taken for medical documentation purposes and will be used only for treatment comparisons and tracking progress milestones.

Client's Initial

Receptionist's Initial

Technician's Initial

I agree that all the above information is true and accurate to the best of my knowledge

Client’s signature: