Hifu - Bodyvision Clinic Prahran

Full Name:*

Address:*

Postcode:*

Date of Birth:*

Email*

Phone*

Please complete required fields

Medical History

Please select Yes or No

Diabetes*

Yes

Asthma*

Yes

Warfarin*

Yes

Hernia*

Yes

Liver Disease*

Yes

Epilepsy/Seizures*

Yes

Thyroid Problems*

Yes

Hormonal Imbalance*

Yes

Suffer from Migraines*

Yes

Do you have any implants?*

Yes

Pacemaker / Heart Condition*

Yes

Immune System Disorder*

Yes

Are you pregnant or breastfeeding*

Yes

Do you have any metal in your body*

Yes

Low or High Blood Pressure*

Yes - Low

Yes - High

Have you had any surgery within the last 9 months?*

Yes

Have you had a cortisone treatment in the last 72 hours?*

Yes

Allergies to medications*

Yes

Name of Medication(s):

Please Read Carefully

I hereby authorise and direct any associates or assistants of Bodyvision Clinic to perform CoolSculpture procedure.

I fully understand that this treatment is purely elective and not medically necessary.

I understand that results will vary from person to person. I understand that I may require multiple treatments. I fully understand that results are not guaranteed.

I also understand that I need to maintain a healthy diet and exercise regime throughout my treatments to achieve the best results.

By signing this consent form, I confirm I am over the age of 18 and have read and fully understand all its contents.

I have had the opportunity to ask questions and receive answers regarding CoolSculpture procedure.

I agree to pay in full for our discussed treatment and understand that there will be no refunds for any performed services.

I understand that I have the right to refuse the proposed procedure at any time prior to its performance.

I Consent*

Yes

BODYVISION CLINICSKIN & BODY

Consent Form: Hifu

About Hifu

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bodyvision.

Skin and body clinic Prahran

Call Us (03) 9529 4559

Text Us 0420 994 040

Skin and Body Treatment Clinic Prahran