Body Contouring Consent Form

Documents informed consent and relevant medical background before performing a body contouring procedure.

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Full Name

First Name

Last Name

Phone Number

Date of Birth

Gender

Male Female Other

I acknowledge that:

Results may vary from person to person Multiple sessions may be required to achieve the desired result The possible risks and side effects of the procedure have been explained to me This procedure is not a substitute for a healthy diet or regular exercise

Further, I acknowledge that:

No specific outcome is guaranteed It is my responsibility to follow the post-procedure care instructions The medical information I have provided is accurate and complete

If the client is a minor, a parent or legal guardian must complete this section

Representative

I am the parent or legal guardian of the client

Name of Legal Guardian/Representative

First Name

Last Name

Signature of Legal Guardian/Representative

Sign here

Date Signed

Signature

Sign here

Date Signed

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