Fat Cavitation & Skin Tightening

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Client Details

Full Name

Date of birth *

Email *

Phone *

Which Part Of The Body Will Undergo Ultrasound Cavitation &/Or RF Tightening Treatment? Please Check. *

Abdomen

Waist

Arms

Neck

Jowles (Jawline)

Thighs

Back (lower)

Back (upper)

Double Chin

Facial

Hips

Cellulite Reduction

BBL

Do you have any of the following? Please check if this applies. Leave blank if none.

Pregnant or breastfeeding

Heart problems or diseases

High blood pressure

Cancer

Kidney damage, diseases or problems

Liver damage, diseases or problems

Acute inflammatory processes

Haemorrhagic disease, trauma or bleeding

Medical plastic parts or parts with metal inside

Abnormal immune system

Numb or insensitive to heat

Menstrual period

Skin conditions such as eczema, dermatitis, or rashes

Active implanted device such as pacemaker or defibrillator

I authorise Lift and Shape to perform this procedure as part of my treatment.

I understand the complications and risks that might happen as a result of this procedure., however, I would still like to proceed.

I release and hold harmless Lift and Shape against any claims, damages, costs, which may occur during or after the procedure.

I understand that I need to follow the pre-care and post-care instructions given to me.

By signing this consent, I confirm that I have read and understood all the information indicated in this document. I also assure you that I'm of legal age. I fully accept all responsibilities for these or any other complications that may occur during the procedure.

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Date Signed *