Client Intake Form – Lipo Laser Personal Information: Name________________________________________________ Address______________________________________________ City / State / Zip _______________________________________ Phone _______________________ DOB _________________ Email ________________________________________________ Date of Initial Visit ____________________ How did you hear about us? ______________________________ Are you now taking or have you recently taken any medication that has caused a photosensitive or photo allergic reaction? Yes No If yes, ________________________________________ Ensure Your Best Results • Drink plenty of water after every treatment • Ensure you undertake physical activity following each treatment to maximize your results • Manage calorie intake; excess calories will counteract the Laser Treatment • Alcoholic beverages and high sugar content drinks must be avoided Procedure Laser paddles will be placed on the exposed area(s) to be treated. It is recommended that a client receive at least 6 treatments over a 45 day period to achieve the maximum potential effect. This treatment should be used in conjunction with a healthy diet and exercise. Risks/Discomfort • Understand all post treatment recommendations and agree to adhere to them • Freely assume any risks of complications or injury from known or unknown causes associated with, relating to, or otherwise arising out of this procedure • Have the right to consent to or refuse any proposed procedure at any time prior to its performance • Have a tattoo in the treatment area that is new or not put on deep enough, that there is a slight risk the area may bleed or blister • Must notify the clinician if my medical history changes prior to subsequent treatments • Release Ionique Wellness Spa LLC from liability associated with this procedure. ___________Initial It is important to know, 100% certainty of success cannot be assured as with any medical procedure. In some cases results may vary and therefore may not always meet expectations of all patients completing a full series of treatments. I have reviewed this consent form. My consent and authorization for this procedure are strictly voluntary. By signing this form I grant authority for Ionique Wellness Spa LLC to perform the described treatment. The purpose of this procedure, risks, complications, alternative methods of treatment have been fully explained to my satisfaction. I have been informed of the potential risks and side effects of Laser Lipo including but not limited to redness, swelling, heat sensitivity, pain and flu like symptoms. Increased bowel movements, urination, and menstrual flow are possible. The nature of the proposed procedure, risks, potential damages and adverse side effects have been explained to me and I fully understand. ___________Initial I understand that a minimum of 6 treatments is required to achieve full results. At that point I will be reevaluated to see if more sessions are needed in order to achieve realistic goals. Clients who are extremely thin may require fewer treatments, while heavier clients may require more. I understand the treatment is most successful if I also maintain a healthy diet and commit to an exercise program. I know that if after the treatment course I gain weight, the results of the Laser Lipo may be reversed. There are few risks associated with laser therapy. This treatment is non-‐invasive and uses a cold output laser. During treatment no discomfort will be present, the client will not feel the laser, however the light will be visible. Although no known detrimental risks exist, potential unknown risks may exist. If you are pregnant or you have a pacemaker, this treatment is not for you. ___________Initial My signature and initials in the next column constitutes my acknowledgment that I’m a competent, consenting adult of at least 18 years of age (or my parent or legal guardian is giving consent on my behalf), and further, that I: I have read and understand all the terms and conditions stated above. No refunds will be given for treatments received. • Have read and understand the information provided in this form • Have had my procedure adequately explained to me by my clinician • Have had the opportunity to ask questions, and all of my questions have been answered to my satisfaction • Have received all of the information I desire concerning my procedure (Printed name of Signatory) _________________________________ I, ____________________________consent to, and authorize Ionique Wellness Spa LLC to perform laser treatment for body contouring and I agree to comply with the recommendations for optimal results. Signature Patient ______________________________________ Date: ___________