Client Medical Consultation/Treatment Record

Are you currently suffering or have ever suffered from any of following?

Do you have any of the following.

Lifestyle question

Client Treatment Consent Form

to perform the iLipo procedure for the purpose of spot fat reduction / improving the appearance of cellulite. I am aware that clinical results may vary depending on individual factors, including medical history, client compliance with pre/post treatment instructions, and individual response to treatment. I have been made aware that my diet and the amount of exercise I do, will have a major effect on the results of my treatments. If I do not make an effort to address my dietary requirements and exercise, I am aware that the results achieved may not be retained.

  • I understand the treatment involves a course of treatment. The fee structure has been fully explained and I understand that I am required to pay for a course of treatment prior to any outstanding treatment value is non refundable.
  • The course cost is

    (Client initials)

  • I certify that I have been fully informed of the nature and purpose of the procedure, expected outcomes and possible complications, and I understand that no guarantee can be given as to the final result obtained. I am fully aware that my condition is of a cosmetic concern and that the decision to proceed is based solely on my expressed desire to do so.
  • I understand that it's my personal responsibility to inform the practitioner of the clinic named above of any changes to my medical history during the course of iLipo treatment sessions and I confirm that should this occur I shall advise the practitioner of any changes.
  • I consent to the taking of photographs and authorize their anonymous use for the purposes of medical audit, education and promotion. Delete if preferred.
  • I certify that I gave been given the opportunity to ask questions, any questions have been answered to my satisfaction and that I have fully read and understood the contents of this consent form.