Self Assessment
Choose Consent Form
velaShape III consent form english
File Number:
VelaShape III Consent Form
Terms and Conditions:
• You are free to resume regular activities. We generally recommend mild exercise post procedure
• Avoid large meals that might expand your stomach
• The result are not guaranteed
• Expect reactions on the treated areas like: redness during the treatment
• Results for same patient on different areas could be different.
• Results from patient to patient also may vary.
• The number of sessions for different areas could be more or less
• Procedure timings vary from area to area and patient to patient
• All the payments are nonrefundable.
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
• My signature below constitutes my acknowledgment and understanding of all this informatio
Patient Name
Patient Signature
Date/Time
Parent or Guardian (if patient is minor)
Witness
Patient Signature
Print
