Non surgical Consultation Form Client Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Gender(Required) Male Female Occupation(Required) Practitioner Name(Required) Address(Required) Street Address Address Line 2 City County / State / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email(Required) Date(Required) MM slash DD slash YYYY Do you have any of the following?(Required) Liver/Kidney Disease Heart conditions including pacemaker, silicosis or other lung conditions Cancer (radiotherapy/chemotherapy) Reynaud's Disease (or other vaso constrict disorders Physical Hypotonic Cardiovascular Disease Cerebral Disease Immune System Disease (ie AIDS or HIV) Urticaria or other immune disorders Hypoproteinaemia Frostbite intolerance Hernia or weak stomach muscle walls Severe diabetes Recent invasive surgery (in last 12 months) Artificial implants (bone, etc) Metal plates or joint implants Sites of prior cosmetic surgery Pregnant or breastfeeding Currently under the influence of drugs or alcohol Hyper or hypotension Scarring history, fibrosis or seborrhoea Haemophilia or other clotting disorders Epilepsy Diabetes Thyroid condition Hormonal imbalances Other immune disorders not listed Received or donated organs Psoriasis or eczema in treatment area High cholesterol Thrombosis (past or present) Broken bones Undiagnosed swelling or inflammation Bruising, cuts or abrasions (treatment area) Fever Varicose veins (treatment area) Any other conditions not listed None of the above If you have answered yes to any of the above, please give full details.(Required)Are you currently taking any medication? If yes, please list all medications.(Required)How is your sleep pattern?(Required) Good Average Poor How is your diet?(Required) Good Average Poor How many hours sleep a night?(Required)How many litres of water do you drink a day?(Required)Do you drink alcohol? If yes, how many units per week?(Required)Do you smoke? If yes, how many cigarettes per day?(Required)Do you exercise? If yes, how much do you exercise per week?(Required)Have you ever had body contouring, fat removal or similar treatments before? If yes, please give details below including the type of treatment and area.(Required)Are you fully committed to making the relevant changes to get the best possible results from your treatment?(Required) Yes No Informed client consent to body sculpting treatment: I consent to, and authorise, Skin & Mind Clinic qualified practitioners to carry out ultrasound cavitation/radio frequency treatments as discussed and agreed.(Required) Yes No The areas to be treated are:The treatment has been fully explained to me. I understand that this treatment will take several sessions and a course of treatments is recommended for best results. * I have been advised that results vary from person to person and that results will also depend on how well I follow my aftercare advice. * I agree to follow all the aftercare advice as provided by my therapist (namely, drinking lots of water, regular body brushing, following a healthy diet and partaking in regular exercise). Whilst I understand that the results from the treatments vary considerably, I accept that all treatments are to be carried out in good faith with the best possible achievable outcome observed. * I understand that there is a risk of some side effects including but not limited to reddening, bruising, tenderness and in rare circumstances there is a small risk of a burn that may or may not lead to scarring. I accept these risks are possible and do not hold the therapist or Skin & Mind Clinic responsible for any adverse reactions that may occur from treatment. * I have asked all relevant questions appertaining to this treatment and am satisfied with the explanation and information given to me regarding the possible side effects and outcome of Ultrasound Cavitation and/or Radio Frequency.(Required) Yes No I have been given full pre and post treatment advice and understand and agree to follow these guidelines at all times during the treatment programme.(Required) Yes No In the unlikely event of an adverse reaction, I will advise Skin & Mind Clinic within 24 hours and, in the case of more serious side effects, will contact my GP to obtain medical advice. I confirm that I am over the age of 18 years • I confirm that I have read and agree to all the guidelines and recommendations of this Informed Consent Form.(Required) Yes No I agree to the Terms and Conditions for Body Contouring Services set out below(Required) Yes No Terms and Conditions for Body Contouring Services: 1. Missed Appointments: If you miss an appointment, it will be deducted from your scheduled sessions. We require a minimum of 48 hours' notice to reschedule an appointment, or you will lose that session. 2. Payment Plans: All payment plans are non-cancellable. If you breach the payment plan agreement, you will be billed for the remaining cost of the services. 3. Consultation and Contract: The consultation form will serve as our binding contract, indicating that you are happy to proceed with the body contouring services. 4. Trust and Breach of Agreement: We are placing our trust in you with the payment plans. Please note that any breach of the agreement will result in us contacting our solicitors. Remember, your body contouring journey is a commitment to yourself. We're here to support you every step of the way, and we're excited to see the amazing results you'll achieve!Signed (please enter your name in the field below) Date MM slash DD slash YYYY