ULTRASONIC CAVITATION DISCLAIMER PATIENT CONSENT: This is an informed consent form that has been prepared to help inform you of the potential benefits and risks of ultrasonic cavitation. It is important that you read this information carefully and discuss fully with your practitioner before proceeding with treatment. It is also important that you take as much time as you need to consider the treatment carefully, weighing up all your options before reaching an informed decision. It is essential that you are aware of your right to have a second opinion and you are encouraged to ask any questions that come to mind throughout the entirety of the process. Ultrasonic cavitation uses energy in the form of ultrasound to break down fat cells (lipolysis), the breakdown products of the fat cells are then naturally removed by the body’s lymphatic system. Ultrasonic cavitation is a form of body contouring, aiming to target small areas of stubborn fat deposits. It is not a weight loss solution and would also never substitute traditional lifestyle measures for weight loss such as healthy diet and regular exercise. Ultrasonic cavitation is however a safer and non-invasive alternative to surgical methods of fat removal such as liposuction. Common areas that can be treated include fat deposits around the abdomen, flanks, hips, face, neck, thighs and upper arms. Ultrasonic cavitation is painless however you will experience a warming sensation when the hand-held probe is applied to the skin. On average 1-3 treatment courses are likely to be needed to achieve results, with results visible by 12 weeks. I am aware that results vary between clients and results are dependent on many individual factors. I am aware that there is no guarantee that I will achieve desired results and that multiple treatment courses may to be needed to achieve desired results. The results of fat cavitation are permanent so long as you do not continue to gain increased body fat following the treatment. I understand that several appointments may be necessary to produce optimal results and I will be notified, in advance of each session of treatment, about the location where the next treatment session is going to take place and the identity of who is going to be involved in my care at each stage. I also understand that I will be kept informed of progress and that I can change my mind at any point. As with any procedure there are potential risks and complications associated. Ultrasonic cavitation is a safe and low risk procedure, but you must be aware of the following possible risks before proceeding. You
must fully discuss any questions with your practitioner. Common side effects following treatment include pain, tenderness, redness and bruising in the treated area. You may also experience a slight headache afterwards. These effects are usually mild and will settle within a few days. You may also experience lumpiness and unevenness in the treated area following the procedure. This is due to uneven resorption of fat and will often resolve with follow up treatments. I have been advised of the relevant information associated with this treatment and I confirm that I fully understand this advice. This includes advice about: - the aims/motivations for having the procedure and the desired outcome - the risks inherent in the procedure - the risks inherent in refusing the procedure - the risks specific to me - the expected benefits of the treatment - the potential disadvantages of the treatment - alternative procedures and their pros and cons - including the option of no treatment at all - any uncertainties about and the likelihood of success of the procedure - any follow-up treatment that may be required
RADIO FREQUENCY DISCLAIMER PATIENT CONSENT: This is an informed consent form that has been prepared to help inform you of the potential benefits and risks of Radio Frequency treatment. It is important that you read this information carefully and discuss fully with your practitioner before proceeding with treatment. It is also important that you take as much time as you need to consider the treatment carefully, weighing up all your options before reaching an informed decision. It is essential that you are aware of your right to have a second opinion and you are encouraged to ask any questions that come to mind throughout the entirety of the process. Radio Frequency treatment is a non-surgical facelifting and body contouring treatment which tightens, smooths and contours the skin. Radio Frequency treatment works by using radio frequencies which are transmitted by a handpiece into the dermis layer of the skin causing heat production. The process triggers new dermal collagen formation resulting in younger tighter and smoother looking skin. Radio Frequency treatment may also help smooth out fine lines and wrinkles and can be used to help reduce cellulite. Radio Frequency treatment can be used to treat loose skin on the neck, jawline, face, legs, abdomen and other body areas. You may experience a warming feeling during the treatment but the procedure is not painful. Other advantages of Radio Frequency treatment: non-invasive, no injections or anaesthetic needed and little to no downtime afterwards. Results are gradual and evolve over a 2-3 month period. Only one treatment is needed and the effects can be expected to last for 2-3 years. I am aware that results vary between clients and results are dependent on many individual factors. I am aware that there is no guarantee that I will achieve desired results. RISKS AND SIDE EFFECTS: As with any procedure there are potential risks and complications associated. Radio Frequency treatment is a safe and low risk procedure, but you must be aware of the following possible risks before proceeding. You must fully discuss any questions with your practitioner. Common risks of Radio Frequency treatment include that it may not be effective with advanced and resilient skin problems. You may also have some mild swelling and redness in the treatment area for 2-3 days afterwards but occasionally can last longer. Uncommon risks include changes in skin pigmentation to lighter or darker, this usually resolves within 6 months but in rare cases could be permanent. Sometimes you may experience some temporary bumps or skin indentations, but these usually resolve naturally. Rare risks of Radio Frequency treatment include pain, tingling or burning sensation after treatment, bruising, blisters, skin burns, permanent scarring or skin indentations are extremely rare risks. In the event of any of these you should consult your practitioner and seek medical advice. I have been advised of the relevant information associated with this treatment and I confirm that I fully understand this advice. This includes advice about: - the aims/motivations for having the procedure and the desired outcome - the risks inherent in the procedure - the risks inherent in refusing the procedure - the risks specific to me - the expected benefits of the treatment - the potential disadvantages of the treatment - alternative procedures and their pros and cons - including the option of -no treatment at all - any uncertainties about and the likelihood of success of the procedure - any follow-up treatment that may be required.
SHOCKWAVE THERAPY DISCLAIMER PATIENT CONSENT: This is an informed consent form that has been prepared to help inform you of the potential benefits and risks of Shockwave therapy. It is important that you read this information carefully and discuss fully with your practitioner before proceeding with treatment. It is also important that you take as much time as you need to consider the treatment carefully, weighing up all your options before reaching an informed decision. It is essential that you are aware of your right to have a second opinion and you are encouraged to ask any questions that come to mind throughout the entirety of the process. Shockwave therapy uses energy in the form of sound waves to create vibrations in the soft tissues. Shockwave therapy is non-invasive and painless, medical uses include treatment of Achilles tendonitis, plantar fasciitis and removal of kidney stones. Cosmetic uses of Shockwave therapy include fat and cellulite reduction and to increase the production of collagen in the skin. In the case of reducing cellulite, the sound waves emitted during Shockwave therapy help to separate fatty acids and glycerol in fat cells. The liquid fat is then removed from the body via the lymphatic system, a process that Shockwave therapy can stimulate.
Shockwave therapy also increases blood circulation, which can aid skin rejuvenation, tightening and reduce lines and wrinkles. Shockwave therapy can be used alone or in conjunction with other body contouring or fat reduction treatments. Note that for fat reduction shockwave therapy is not a substitute for healthy diet and regular physical exercise. I am aware that results vary between clients and results are dependent on many individual factors. I am aware that there is no guarantee that I will achieve desired results and that multiple treatment courses may to be needed to achieve or maintain desired results. Your practitioner will discuss how many treatments you will need and over what timeframe, depending on the aim of treatment. Results can be seen after 1 week, but maximal effects evolve over a period of 2-3 months following treatment. I understand that several appointments may be necessary to produce optimal results and I will be notified, in advance of each session of treatment, about the location where the next treatment session is going to take place and the identity of who is going to be involved in my care at each stage. I also understand that I will be kept informed of progress and that I can change my mind at any point. RISKS AND SIDE EFFECTS: As with any procedure there are potential risks and complications associated. Shockwave therapy is a safe and low risk procedure, but you must be aware of the following possible risks before proceeding. You must fully discuss any questions with your practitioner. Most clients do not experience side effects however some common after effects include tissue swelling, reddening, soreness, tingling or numbness. These effects are usually mild and resolve naturally after 7 days, although they may last longer. Rare risks include haematoma (extensive bruising), petechiae (minor broken blood vessels) and damage to soft tissue e.g. tendon or ligament injury or rupture. I have been advised of the relevant information associated with this treatment and I confirm that I fully understand this advice. This includes advice about: - the aims/motivations for having the procedure and the desired outcome - the risks inherent in the procedure - the risks inherent in refusing the procedure - the risks specific to me - the expected benefits of the treatment - the potential disadvantages of the treatment - alternative procedures and their pros and cons - including the option of no treatment at all - any uncertainties about and the likelihood of success of the procedure - any follow-up treatment that may be required
CLINICAL PHOTOS AND VIDEOS: I agree to and authorise the taking of clinical photographs and videos. I understand that these clinical photographs and videos will form part of and will be kept with my confidential medical records. I have been asked what information I want and would need in order to make an informed decision. I have been given the opportunity to discuss my desired outcome fully in order for me to make an informed decision. I certify that I have read the above consent and that I fully understand it. I have been given ample opportunity for discussion and all my questions have been answered to my satisfaction. No new information has become available that affects my decision to have the treatment or my decision to consent. I hereby consent to this procedure. This constitutes the full disclosure and supersedes any previous verbal or written disclosures.