Body Sculpting Treatment Consent
Please complete this treatment consent form for your provider. Please acknowledge that all risks and potential side effects and before and after care instructions have been discussed with you prior to receiving treatment at Desert Hills Rejuvenation.
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Email *
Patient Name and Date of Birth: *
Please consent to your treatment at Desert Hills Rejuvenation only if you understand:
  • Why the treatment is being performed
  • The type of anesthetic (if any) used
  • Potential wound aspects and risks of treatment
  • The final result cannot be guaranteed as every patient has different anatomy and healing processes
  • You are expected to follow before and after care guidelines to optimize desired results and to avoid undesirable outcomes.
Contraindications for having this treatment:
Menstruation (applies only to the treatment of the abdomen)
Metal implants in or around the treatment area
Skin infections and diseases
Acute fever
Thyroid disease and other hormonal disorders
Any other chronic diseases
Heart diseases or pacemakers
Autoimmune diseases, HIV or AIDS
Severe high blood pressure or circulation problems
Cancer
Deep vein thrombosis or varicose veins
Epilepsy
Hemorrhagic disease, trauma, vascular rupture
Pregnant or breastfeeding
Infectious diseases
Inflammation of the veins, phlebitis
Copper Intrauterine device or IUD (applies only to the treatment of the abdomen)
Wounds, sores, lesions
Treatment with anti-inflammatories, anticoagulants, antibiotics
Under 18
Liver or kidney disease
Treatment you are having at Desert Hills Rejuvenation: *
Initial to acknowledge that potential risks and complications have been reviewed with your provider: *
Please sign and date to give consent for treatment as described by your provider. 
I understand the information provided to me, understand the reasons for treatment and agree to follow before and after care guidelines.

Signature:
 *
Date and Time: *
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