Ultrasound Cavitation Treatment & RF ConsentFirst Name *Last Name *Date / Time *Email *Phone *Ultrasound Cavitation Treatments Check all that apply: AbdomenInner ThighCalfUpper Legs “Saddle Bags”Inner ThighArms (triceps side)BackButtocksFlanks “Love Handles”Are you pregnant or nursing? *YESNODo you have any acute inflammation? *YESNODo you have any plastic or bone cement or any large metal implant? *YESNODo you have hemophilia? *YESNODo you have a Neurological disorder? *YESNODo you have any current infection? *YESNODo you have any type of heart, kidney, liver disease *YESNOAre you epileptic? *YESNODo you have a wound that has not healed? *YESNOHave you had any abdomen operations? *YESNODo you have melanoma? *YESNOAre you being treated with anticoagulants? *YESNODo you have any infectious disease or tuberculosis? *YESNODo you have any kind of tumor or cancer? *YESNODo you have current or any history of internal bleeding? *YESNODo you have any abnormally high or low blood pressure? *YESNODo you have thrombosis and / or thrombophlebitis? *YESNODo you have any keloid? *YESNODo you have advanced untreated diabetes? *YESNODo you have any cardiac or vascular disease or condition? *YESNODo you have current or any history of internal bleeding? *YESNODo you have high levels of Triglycerides (hereditary)? *YESNOHave you undergone a transplant? *YESNODo you have any kind of heart trouble? *YESNODo you have a communicable disease? *YESNOIF YOU ANSWERED “YES” TO ANY OF THESE QUESTIONS YOU MAY NOT BE ELIGIBLE FOR THE TREATMENT. Explain any Yes answers: Disclosure. This treatment is a process and subsequent visits may be necessary in order to achieve the desired results. Subsequent visits are subject to additional charges per visit which depend on the amount of work needed. Actual results vary from person to person and Crystal Reiki & Healing by Sheena, LLC does not guarantee any specific result. The RF (Radio Frequency) treatment carries with it possible health complications and consequences, which include but might not be limited to the risk of kidney failure, liver failure, pacemaker failure, birth defect, miscarriage, thyroid damage, damage to the ovaries, lactation complications, hyper-triglyceridemia, hyper-cholesterolemia, pancreatitis, infection, scarring and/or allergic reaction to any products used, excessive thirst, dehydration, nausea. The RF (Radio Frequency) treatment includes, but is not limited to, the use of high-power low-frequency RF (Radio Frequency) which uses 25-28KHz frequency ultrasound to penetrate the skin and assist with the breakdown of fat cells by creating micro-bubbles that increase the pressure around the adipocyte and force it to implode, thus breaking down adipocyte’s cell membrane. After Care. After care instructions must be followed explicitly, whether given in writing or orally. Failure to follow after care instructions may compromise the final results of the treatment. Before, During and After Pictures. Before, during and after pictures or videos may be taken to document the treatment. These pictures s or videos become Crystal Reiki & Healing by Sheena, LLC sole property and may only be used for its legitimate business purposes. Release. I recognize that there are certain inherent risks associated with the above-described treatment and I assume full responsibility for personal injury to myself. In exchange for such treatment, I hereby fully release and forever discharge Crystal Reiki & Healing by Sheena, LLC (including its officers, members, owners, employees and agents) from any and all damages, costs, expenses, liabilities, causes of action, claims and demands, of whatever character, in law or in equity, whether known or unknown, direct or indirect, asserted or unasserted, and whether or not on account of myself, Crystal Reiki & Healing by Sheena, LLC. or other third parties, or in any way arising out of the above described treatment I have requested Sheena Apostolopoulos to perform. It is the intention of the parties that this agreement binds all parties whose claims may arise out of or relate to the treatment or services provided by Crystal Reiki & Healing by Sheena, LLC including any spouse or heirs of the client/patient and any children, whether born or unborn. Any legal or equitable claim that may arise from participation in the treatment shall be resolved under Pennsylvania law. I agree to indemnify, hold harmless and defend Crystal Reiki & Healing by Sheena, LLC, LLC (including its officers, members, owners, employees and agents) against all third-party claims, causes of action, damages, judgments, costs or expenses, including attorneys’ fees and other litigation costs, which may in any way arise from the above described treatment I have requested Crystal Reiki & Healing by Sheena, LLC to perform. By signing this agreement I confirm that I am over the age of 18, I understand that the RF (Radio Frequency) procedure is permanent, that such procedure has possible adverse consequences and that the procedure is for cosmetic purposes only. I certify that I have read the above paragraphs; had the procedure and risks explained to me, fully understand this consent and procedure form and herby consent to the indicated procedure(s). This means that I accept full responsibility for these and/or any other complications which may arise or result during or following the RF (Radio Frequency), Coolsculpting, RF, and any other noninvasive procedure which is to be performed at my request according to this agreement and I herby agree to wave any arbitration of any malpractice claim. I further understand that by signing this agreement, I surrender certain legal rights. *I have read, consent, and understandInitials *Signature * Date / Time EmailSubmit
