SculpSure Consent Form
Terms and Conditions:
• Any contraindications will void this offer and treatment
• This treatment cannot be transferred to another person
• Once the machine has been turned on, refunds are prohibited
• Appointments preferences are based on machines availability
• By utilizing the provided offer you hereby agree to all terms and
conditions related to this offer
• I fully consent to all treatments provided in this package, and have read
and signed the consent forms
• Medical Village reserves the right to change or cancel any or all of the
terms and conditions without prior notice in its sole discretion.
• The result are not guaranteed
I am a competent consenting adult of at least 18 years of age (or my parent
or legal guardian is giving consent on my behalf), and further:
• Pre and post treatment instructions have been explained to me
• Have had the opportunity to ask questions, and all of my questions have
been answered to my satisfaction
• Must notify the clinician if my medical history changes prior to
subsequent treatments
• I consent to clinical photographs being taken of my treated areas for my
personal health record only
• My signature below constitutes my acknowledgment and understanding
of all this information
Patient Name
Patient Signature
Date & Time