Loading...

COSMED LASER SPA 

Reason/Benefits: For body contouring/shaping, melting localized fat, and cellulite reduction.  

Risks, side effects, and complications: pain, bruising, discoloration, infection, burn, scar, and ineffective treatment. To prevent injury, the treatment setting will be set at a lower and safer setting, if your skin is dark or if you are tanned. This will likely decrease the efficacy of the treatment. As such, it is important to avoid sun exposure and to wear sun block every day to reduce risk of complications. If you are tanned or have excessive sun exposure, please reschedule your appointment at least 6-8 weeks later for a safe and comfortable treatment. Also, avoid caffeinated products or NSAIDs to minimize risk of bruising. Do not stop NSAIDs if it is prescribed to you by your doctor for medical reasons.  

Alternative: Exercises, diet, and lifestyle changes. Thermage, liposuction (Smart Lipo/Laser Lipo), fat dissolving injections, body wrap, and others procedures.  

Frequency and duration: For optimal treatment, you will need at least 2-3 sets of 3-4 treatments with each set done. Each treatment is done on a weekly interval. With each treatment you can expect some degree of skin tightness and circumferential reduction of the treated area. You can expect some degree of size reduction/body shaping, skin tightness, and cellulite reduction.  

Treatment: a hand piece with a combination of laser, radiofrequency, suction, and rolling will be applied to the skin of the treatment area and with each pulses, you will feel a “hot sensation.” Please let the doctor/operator know if you are feeling pain instead of tolerable discomfort. Treatment oil will be applied to your skin before treatment.  Duration of treatment: 20 minutes for each session. 

Post treatment precautions: Avoid sun exposure, tanning booths, spray tan, and wear sun screen on a daily basis. Apply ice, aloe vera, and topical OTC cortisone if you feel heat or swelling in the treated area. Reschedule if you are tanned either from sun/tanning booths or sprayed tan or had sun exposure.  

Post treatment expectation: For the first few days, there might be some redness or swelling over the treated area. If bruising occurs it will generally resolved within a couple of weeks. You will feel some degree of tightness and smoothness after each treatment.  

I consent to the treatment known as the Vela Shape treatment. This treatment has been explained to me and I have had the opportunity to ask questions regarding the procedure. I understand that these treatments are not an exact science and the degree of my improvement is variable.  

 

By my signature below, I acknowledge that I have read the information and consent and that I have been given the opportunity to ask questions and that my questions have been answered to my satisfaction, and I don’t have an unrealistic expectation.  I have been adequately informed of the risks and benefits of this treatment and I wish to proceed with the Vela Shape treatment.  

I also understand that any appointment that I make that is not cancelled within 48 hours I will be charged a ($50 or forfeiture of one of the treatment) no show fee

 

First Client's Name

First Name*

Last Name*

Phone*
First Client's Age Acknowledgment*
First Client's Date of Birth*
I certify that I am 18 years of age or older
First Client's Information
Have you ever used Accutane?*
No
Yes

If Yes, when did you last use it?
What topical medications or creams are you currently using?
Retin-A

Others (Please list):
Have you had any recent tanning or sun exposure in the last two weeks that changed the color of your skin?*
No
Yes
Have you recently used any self-tanning lotions or treatments?*
No
Yes
Do you form thick or raised scars from cuts or burns?*
No
Yes

FOR OUR FEMALE CLIENTS:

Are you pregnant or trying to become pregnant?*
No
Yes
Are you breastfeeding?*
No
Yes

Occupation
First Client's Signature*
Second Client's Name

First Name*

Last Name*
Second Client's Date of Birth*
Second Client's Information
Have you ever used Accutane?*
No
Yes

If Yes, when did you last use it?
What topical medications or creams are you currently using?
Retin-A

Others (Please list):
Have you had any recent tanning or sun exposure in the last two weeks that changed the color of your skin?*
No
Yes
Have you recently used any self-tanning lotions or treatments?*
No
Yes
Do you form thick or raised scars from cuts or burns?*
No
Yes

FOR OUR FEMALE CLIENTS:

Are you pregnant or trying to become pregnant?*
No
Yes
Are you breastfeeding?*
No
Yes

Occupation
Third Client's Name

First Name*

Last Name*
Third Client's Date of Birth*
Third Client's Information
Have you ever used Accutane?*
No
Yes

If Yes, when did you last use it?
What topical medications or creams are you currently using?
Retin-A

Others (Please list):
Have you had any recent tanning or sun exposure in the last two weeks that changed the color of your skin?*
No
Yes
Have you recently used any self-tanning lotions or treatments?*
No
Yes
Do you form thick or raised scars from cuts or burns?*
No
Yes

FOR OUR FEMALE CLIENTS:

Are you pregnant or trying to become pregnant?*
No
Yes
Are you breastfeeding?*
No
Yes

Occupation
Fourth Client's Name

First Name*

Last Name*
Fourth Client's Date of Birth*
Fourth Client's Information
Have you ever used Accutane?*
No
Yes

If Yes, when did you last use it?
What topical medications or creams are you currently using?
Retin-A

Others (Please list):
Have you had any recent tanning or sun exposure in the last two weeks that changed the color of your skin?*
No
Yes
Have you recently used any self-tanning lotions or treatments?*
No
Yes
Do you form thick or raised scars from cuts or burns?*
No
Yes

FOR OUR FEMALE CLIENTS:

Are you pregnant or trying to become pregnant?*
No
Yes
Are you breastfeeding?*
No
Yes

Occupation
Fifth Client's Name

First Name*

Last Name*
Fifth Client's Date of Birth*
Fifth Client's Information
Have you ever used Accutane?*
No
Yes

If Yes, when did you last use it?
What topical medications or creams are you currently using?
Retin-A

Others (Please list):
Have you had any recent tanning or sun exposure in the last two weeks that changed the color of your skin?*
No
Yes
Have you recently used any self-tanning lotions or treatments?*
No
Yes
Do you form thick or raised scars from cuts or burns?*
No
Yes

FOR OUR FEMALE CLIENTS:

Are you pregnant or trying to become pregnant?*
No
Yes
Are you breastfeeding?*
No
Yes

Occupation
Sixth Client's Name

First Name*

Last Name*
Sixth Client's Date of Birth*
Sixth Client's Information
Have you ever used Accutane?*
No
Yes

If Yes, when did you last use it?
What topical medications or creams are you currently using?
Retin-A

Others (Please list):
Have you had any recent tanning or sun exposure in the last two weeks that changed the color of your skin?*
No
Yes
Have you recently used any self-tanning lotions or treatments?*
No
Yes
Do you form thick or raised scars from cuts or burns?*
No
Yes

FOR OUR FEMALE CLIENTS:

Are you pregnant or trying to become pregnant?*
No
Yes
Are you breastfeeding?*
No
Yes

Occupation
Seventh Client's Name

First Name*

Last Name*
Seventh Client's Date of Birth*
Seventh Client's Information
Have you ever used Accutane?*
No
Yes

If Yes, when did you last use it?
What topical medications or creams are you currently using?
Retin-A

Others (Please list):
Have you had any recent tanning or sun exposure in the last two weeks that changed the color of your skin?*
No
Yes
Have you recently used any self-tanning lotions or treatments?*
No
Yes
Do you form thick or raised scars from cuts or burns?*
No
Yes

FOR OUR FEMALE CLIENTS:

Are you pregnant or trying to become pregnant?*
No
Yes
Are you breastfeeding?*
No
Yes

Occupation
Eighth Client's Name

First Name*

Last Name*
Eighth Client's Date of Birth*
Eighth Client's Information
Have you ever used Accutane?*
No
Yes

If Yes, when did you last use it?
What topical medications or creams are you currently using?
Retin-A

Others (Please list):
Have you had any recent tanning or sun exposure in the last two weeks that changed the color of your skin?*
No
Yes
Have you recently used any self-tanning lotions or treatments?*
No
Yes
Do you form thick or raised scars from cuts or burns?*
No
Yes

FOR OUR FEMALE CLIENTS:

Are you pregnant or trying to become pregnant?*
No
Yes
Are you breastfeeding?*
No
Yes

Occupation
Ninth Client's Name

First Name*

Last Name*
Ninth Client's Date of Birth*
Ninth Client's Information
Have you ever used Accutane?*
No
Yes

If Yes, when did you last use it?
What topical medications or creams are you currently using?
Retin-A

Others (Please list):
Have you had any recent tanning or sun exposure in the last two weeks that changed the color of your skin?*
No
Yes
Have you recently used any self-tanning lotions or treatments?*
No
Yes
Do you form thick or raised scars from cuts or burns?*
No
Yes

FOR OUR FEMALE CLIENTS:

Are you pregnant or trying to become pregnant?*
No
Yes
Are you breastfeeding?*
No
Yes

Occupation
Tenth Client's Name

First Name*

Last Name*
Tenth Client's Date of Birth*
Tenth Client's Information
Have you ever used Accutane?*
No
Yes

If Yes, when did you last use it?
What topical medications or creams are you currently using?
Retin-A

Others (Please list):
Have you had any recent tanning or sun exposure in the last two weeks that changed the color of your skin?*
No
Yes
Have you recently used any self-tanning lotions or treatments?*
No
Yes
Do you form thick or raised scars from cuts or burns?*
No
Yes

FOR OUR FEMALE CLIENTS:

Are you pregnant or trying to become pregnant?*
No
Yes
Are you breastfeeding?*
No
Yes

Occupation
Client's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Age Acknowledgment*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information
Have you ever used Accutane?*
No
Yes

If Yes, when did you last use it?
What topical medications or creams are you currently using?
Retin-A

Others (Please list):
Have you had any recent tanning or sun exposure in the last two weeks that changed the color of your skin?*
No
Yes
Have you recently used any self-tanning lotions or treatments?*
No
Yes
Do you form thick or raised scars from cuts or burns?*
No
Yes

FOR OUR FEMALE CLIENTS:

Are you pregnant or trying to become pregnant?*
No
Yes
Are you breastfeeding?*
No
Yes

Occupation
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver - TRY IT FREE!