DECLARATION OF CONSENT FOR THE BE LIFTED TREATMENT

Please complete

the form below:

Client Details

Full Name *

Phone *

Email *

Address *

Would you like to receive our monthly emails with currents specials:

Yes

I have been personally advised by the handler about the type, kind and purpose of the treatment, including information about possible anesthetization.

I was thoroughly informed about the required behaviour, as well as the necessary sun protection before and after the treatment, and pointed out possible complications before and after the treatment.

In doing so, my personal situation was sufficiently discussed, as well as realistic treatment results.

I have received, read and understood the leaflet with general information for after-care.

I was also able to ask questions about the procedure, these were answered and understood by me i.e Specific personal risk factors of the patient (medication, operations, sensitivity to light and disorders)

In order to be able to perform your Be Lifted Body NZ treatment optimally, we ask you to answer the following questions

Are you HIV positive *

Yes

Were you, or will you be treated with cortisol during the treatment *

Yes

Do you suffer from heart problems *

Yes

Do you have a pacemaker *

Yes

Allergies

Do you take blood thinning drugs *

Yes

Do you have a healing disorder *

Yes

Do you suffer from cold sores *

Yes

Infectious diseases *

Yes

If yes which disease

Have you had a Covid-19 vaccine in the last 2 weeks *

Yes

Are you scheduled to receive a Covid-19 vaccine in the next 2 weeks *

Yes

Do you give permission for images taken to be used for promotional purposes *

Yes

RISKS

EVEN IF THE THERAPY IS CARIED OUT IN THE CORRECT MANNER THERE ARE CERTAIN RISKS, LISTED BELOW

• Intolerance of local anaesthetic (cream form)

• Intolerance of the Colloidal silver (gel form)

• Wound infection/ wound healing disorder/ scarring (extremely rare)

• Pigment disorder (hyperpigmentation) A SUNSCREEN WITH SPF 50 SHOULD BE USED FOR AT LEAST 4 WEEKS AFTER TREATMENT

DECLARATION

I am aware that a guarantee cannot be given for the results of the treatment.

I have also been informed about the necessity of additional treatments (fee required), which may be necessary to achieve desired results.

I agree to carry through with the above described treatment.

I have been given sufficient time and opportunity to contemplate my decision and I do not have any further questions, as all of my questions have been answered completely and fully understood.

I have received and read the patient information. I will follow the instructions and agree to the fibroblast lift treatment.

I agree to the procedure with Be Lifted Body NZ

Signature

Clear

Date:

Fibroblast Contouring Consent

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