LPG Endermologie Consent Form

Ultraformer MPT Patient Consent Form

CLIENT DETAILS

Address

MEDICAL HISTORY

Medical History

CLIENT CONCERNS

Client Concerns

PRACTITIONER ASSESSMENT

Cellulite Grade
Assessment Findings

LPG Endermologie Information

LPG Endermologie is a non-invasive mechanical stimulation treatment designed to support lymphatic drainage, circulation, body contouring, cellulite reduction, fibrosis management and skin firming.

EXPECTED RESULTS & LIMITATIONS

Expected Results & Limitations(Required)

Contraindications

  • Active Cancer (unless medically cleared)
  • Deep Vein Thrombosis (DVT)
  • Active Infection
  • Fever
  • Open Wounds
  • Severe Inflammation
  • Severe Cardiac Disease
  • Severe Varicose Veins requiring clearance

RISKS & POSSIBLE SIDE EFFECTS

Risks & Possible Side Effects Acknowledged(Required)

PHOTOGRAPHY, VIDEO & MARKETING CONSENT

Photography & Marketing Consent(Required)
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PRIVACY POLICY

Privacy Policy Consent(Required)

Clinical records and photographs may be retained according to Australian law and insurer requirements.

FINANCIAL, REFUND & CANCELLATION POLICY

Completed treatments are non-refundable except where required by Australian Consumer Law. Late cancellations and no-shows may result in fees or loss of deposit.

COMPLAINTS POLICY

Complaints Policy Agreement(Required)

PATIENT DECLARATION

Patient Declaration(Required)

TREATMENT RECORD

Treatment Area

Aftercare

  • Drink plenty of water
  • Maintain normal activity and movement
  • Follow practitioner recommendations
  • Contact the clinic if unusual symptoms occur

FOLLOW-UP REVIEW

SIGNATURES

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