THERMOGENESIS CONSENT FORM

Name

Date

Dob

Street Address

City

State/Province

ZIP / Postal Code

Phone Number *

Email Address *

if Lipoma is being treated has this been diagnosed by a medic?

YesNo

If you answered yes then please elaborate below

Please list any medications you are on below

Name

IHave read through the above and answered honestly, I understand the treatment in its entirety and consent to undergo the treatment, I understand that it is my responsibility to declare any contra indications to treatment.

Client Signature

Date

accredited aesthetics practitioner signature

Date

THERMOGENESIS CONSENT FORM

Thermogenesis Tretment Area (tick all that apply)

if Lipoma is being treated has this been diagnosed by a medic?

Medical History - Don you have a history of the following (tick all that aply)