Venus Freeze Consent Form
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Name
Email
Phone
Treatment site(s)
I understand that there is a possibility of short-term side effects from the Freeze treatment. I could experience edema (swelling), prolonged redness in the area treated as well as slight heat discomfort/tingling. These side effects have been fully explained to me during my consultation/treatment.
I acknowledge that patient results may vary depending on many factors including, but limited to, medical history, and individual's response to treatment; patient compliance with pre and post treatment instructions or changes in medical condition prior to, during or after treatment has been completed.
I agree (if required/requested) to the photographing of appropriate portions of my body for medical, scientific or educational purposes, provided they do not reveal my identity. I understand that the Freeze treatment protocol involves a series of treatments with a specific protocol involved along with a fee structure associated to this series. I agree to follow this treatment protocol and fee structure as it was explained to me and it has been explained to me by my aesthetician in a way that I understand:
I agree (if required/requested) to the photographing of appropriate portions of my body for medical, scientific or educational purposes, provided they do not reveal my identity. I understand that the Freeze treatment protocol involves a series of treatments with a specific protocol involved along with a fee structure associated to this series. I agree to follow this treatment protocol and fee structure as it was explained to me.
It has been explained to me by my aesthetician in a way that I understand: The above treatment or procedure to be undertaken; There are risks to the procedure/treatment and I have been explained on what those risks are; There is no guarantee on the final results that I will obtain; The decision to proceed is based solely on my expressed desire to do so; That I have informed the staff about current or past medical conditions, disease or medication that I am taking; Any questions I may have asked have been answered to my satisfaction.
I CONSENT TO THE TREATMENT OR PROCEDURE AND THE ABOVE LISTED ITEMS AND I AM SATISFIED WITH THE EXPLAINATIONS GIVEN.
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