ULTRASONIC CAVITATION 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 skin conditions, infections, inflammation, or open wounds in the area to be treated?

Yes

If Yes, please specify:

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

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:

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 an ultrasonic cavitation body contouring treatment, which is a non-invasive procedure designed to reduce localized fat deposits, improve body contour, and enhance overall skin appearance.

Ultrasonic cavitation uses low-frequency ultrasound waves to target fat cells beneath the skin. These sound waves create pressure changes that help break down fat cells into a liquid form, which is then processed and eliminated naturally by the body through the lymphatic and metabolic systems.

During the procedure, a handheld device will be applied to the targeted areas of the body using a conductive gel. The device delivers ultrasonic energy into the treatment area while remaining safe and comfortable for the surrounding tissues. This process is intended to reduce the appearance of stubborn fat and improve body contour in specific areas.

The treatment is generally comfortable and may produce sensations such as warmth, mild vibration, or a light buzzing sound in the ears due to the ultrasonic frequencies. The intensity may vary depending on the treatment area and individual sensitivity.

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

Benefits and Risks

I have been informed that the potential benefits of ultrasonic cavitation treatment may include:

Reduction in the appearance of localized fat deposits
Improved body contour and more sculpted appearance
Non-invasive fat reduction with no downtime
Smoother skin texture in the treated area
Reduction in the appearance of cellulite
Targeting of stubborn fat areas resistant to diet and exercise

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

Mild warmth, tingling, or vibration sensations during the procedure
Temporary redness, swelling, or tenderness in the treated area
Increased urination as the body processes and eliminates broken-down fat cells
Uneven results or the need for multiple sessions to achieve desired outcomes

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 Ultrasonic Cavitation 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 Ultrasonic Cavitation 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 Ultrasonic Cavitation 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: