INFORMED CONSENT FORM

Patient name Treatment sites I duly authorize to perform VelaShape treatment.
I understand that the VelaShape is a device used for improving the appearance of cellulite and reducing circumferences and that if may also be therapeutic for improving circulation and muscle aches in the treated areas. I understand there is possibility of shirt-term temporary discoloration of the skin, as well as rare side effects such as scarring and permanent discoloration. These effects have been fully explained to me (patient's initials). I understand that clinical results may vary depending on individual factors, including but not limited to medical history, skin type, patient compliance with pre- and post-treatment instruction, and individual response to treatment. I understand that treatment with the VelaShape involves a series of treatments and the fee structure has been fully explained to me (patient's 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 cosmetic concern and that the decision to proceed is based solely on my expressed desire to do so. I confirm that I have informed the staff regaring any current or past medical condition, disease or medication taken. I consent to the taking of photographs and authorize their anonymous use for the purposes of medical audit, education and promotion. I certify that I have been given the opportunity to ask questions and that I have read and fully understand the contents of this consent form.
Patient Signature :
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Date : Witness :