New Lipo Light Therapy Client Registration Form

Name*

First NameLast Name
Cell Number:*

Area CodePhone Number
E-mail*
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
How did you hear about us?*
Marital Status
Weight (pounds)*
Sex:
Date of Birth*

MonthDayYear
In case of emergency...
Height (inches)
Emergency Contact:

First NameLast Name
Relationship
Contact Number

Area CodePhone Number
Taking any medications, currently?*

YesNo
If yes, please list it here
Contouring Questions
With realistic expectations, how many inches are you wanting to lose on the area listed above
How serious are you about your therapy?

Not very seriousSomewhat seriousVery serious
What area will we be treating?
On a scale of 1-10 please rate your understanding of the Lipo Light procedure.
How much weight have you gained in the past year?
On a scale of 1-10 how committed are you to this procedure.
Do you understand that the Lipo Light procedure is primarily a tool to be used with diet and daily exercise?
Are you interested in hearing how you can improve your Lipo Light results?
Are you ready to commit to a Lipo Light treatment program to reduce or eliminate yor area of treatment?
In a few words describe how you feel about your current weight.

Consent for Treatment
I duly authorize the technicians of Lipo-Light to perform the procedure for the purpose of body contouring, lymphatic drainage, improving the appearance of cellulite and skin tightening. I am aware that clinical results may vary depending on individual factors, including medical history, patient compliance with pre/post treatment instructions, and individual response to treatment. I have been made aware that my diet and the amount of exercise I do will have a major effect on the results of my treatments.

If I do not make an effort to address my diet and exercise I am aware that the results achieved may not be retained. I understand that treatment by Lipo-Light involves a course of treatments. The fee structure has been fully explained and

I understand that I am required to pay for a course of treatments prior to any procedures taking place. I am fully aware that should I wish to cancel the course, the value of the outstanding treatment is non refundable. Due to demand for treatments we schedule all appointments following the initial consultation. Please be aware that all cancellations require a minimum of 24 hours notice. Failure to do so will result in that treatment being deducted from your course without a refund. It is important to be aware that this may have a negative effect on your overall results. Any changes to the initial treatment dates will be subject to availability. If you are more than 10 minutes late we may not be able to accommodate your treatment appointment, as this may inconvenience other clients. PWLC reserves the right to deduct a treatment from your treatment course without a refund.

I certify that I have been fully informed of the nature and purpose of the Lipo-Light 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 a cosmetic concern and that the decision to proceed is based solely on my expressed desire to do so. I am aware that the Lipo Light may cause slight hypo/hyper-pigmentation of the skin and treatment is taken at my own risk (tattoo areas should be avoided).

I agree that I have read the Lipo Light Therapy Service FAQ's on the touchandglowstudio.com website

I understand that it is my personal responsibility to inform the therapist of any changes to my medical history during the course of treatment sessions and I confirm that should this occur I shall advise the therapist of any changes. I consent to the taking of photographs and authorise their anonymous use for the purposes of medical audit, education and promotion. I certify that I have been given the opportunity to ask questions and that I have read and fully understand the contents of this consent form.

By submitting this form you consent to treatment and the above consent form.
Initials
Should be Empty:

Contouring Questions