Fat Dissolve Consent Form

Please fill out the following form to help us understand your physical condition.

First Name

Last Name

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Phone

Email Address

Emergency Contact

Date of Birth

Sex

Male

Female

Emergency Contact Phone

I would like to be added to your email list for specials and discounts.

How would you describe your skin?

Oily

Dry

Combination

Sensitive

How would you describe your stress level?

Little

Moderate

High

Severe

Do you feel your stress level may be affecting the health of your skin?

Yes

Are you in good health overall?

Yes

If no, list concerns:

Are you currently under the care of a physician?

Yes

If yes, explain:

Do you have any allergies to foods or medications?

Yes

If yes, explain:

Are you currently on any medications either topical or oral?

Yes

If yes, please list:

How do you heal after an acne breakout, cut or scratch?

No Scar

Red

Brown (PIH)

Do you smoke?

Yes

Are you prone to cold sores?

Yes

If yes, date of last cold sore?

Do you have an allergy to Latex?

Yes

Do you tan in the sun or in tanning beds/booths?

Yes

Anything else we should know:

The answers I have provided are true and correct to the best of my knowledge.

Full Name

Your Signature

Select a date

I, (Your Name), voluntarily consent to undergo Lipodissolve treatments.

I understand that Lipodissolve can be used for many reasons. I want to have treatment of the following:

I hereby consent to the Lipodissolve treatment of which I understand that more than (1) treatment is required. I understand that the treatment requires many small injections in and around the area(s) to be treated. I understand that the administration of topical anesthesia may be used if deemed necessary.

I understand that the benefits with Lipodissolve will vary but may include: a decrease of cellulite and increase of skin tone, a decrease of wrinkles and may eliminate or decrease pain. I fully understand that there are alternative treatments available for the reduction of wrinkles, cellulite, fat, and pain.

I understand that there are some risks with any procedure. The following is a list of potential risks with Lipodissolve.

Bruising of the skin (minimally)
Swelling, redness, or nodules are possible depending on location treated
Nausea, dizziness, and possible allergic reaction to the Hyaluronidase may occur
Skin infection is a possibility with any injection type procedure

I understand that Lipodissolve is relatively new in the USA, but has been used in Europe for over 50 years.

I acknowledge that I have been informed about the serums that will be used in my treatment and give consent to their use in my treatment. I know that Lipodissolve is not an exact science; therefore, no guarantee can be made as to the results of my treatment. I understand that this treatment is strictly for cosmetic purposes and will not be covered by insurance.

By my signature, I certify that I have thoroughly read and understand the contents of this form and the disclosures listed above were made to me and that if my medical history/status changes I will notify the Alpha Woman Studios immediately. I have been given ample opportunity to have all of my questions and concerns answered.

Alpha Woman Studios Cancelation Policy

Your appointment is very important. We understand that sometimes schedule adjustments are necessary. Therefore, we respectfully request at least 24 hours' notice prior to your scheduled appointment time for cancellations or rescheduling appointments.

Please notify us by e-mail if your cancellation is outside of our normal business hours or you're unable to reach us by phone at (213) 249-2613.

Any appointments cancelled/rescheduled or changed without 24 hours notice will result in a charge equal to 50% of the reserved service amount. All "No Shows" will be charged 100% of the reserved service amount.

Please remember that it is your responsibility to remember your appointment dates and times in order to prevent any missed appointments which result in a cancellation fee. Not receiving an electronic notification of your appointments from us is not sufficient reason to miss an appointment if the original confirmation notification was received timely.

Full Name

Your Signature for Cancellation Policy

Select a date

Alpha Woman Studios Photo & Video Release

I hereby grant and authorize Eva/Jazmine and Alpha Woman Studios the right to take, edit, alter, copy, exhibit, publish, distribute and make use of any and all pictures, video, and/or audio taken of me to be used in and/or for any lawful promotional materials including, but not limited to, newsletters, flyers, posters, brochures, advertisements, press kits, websites, social networking sites and other print or digital communications without payment or any other consideration.

This authorization extends to all languages, media, formats, and markets now known or later discovered.

I waive the right to inspect or approve the finished product wherein my likeness appears, including written or electronic copy.

I hereby hold harmless and release Eva, Jazmine, and Alpha Woman Studios from all liability, petitions, and causes of action which I, my heirs, representatives, executors, or any other persons may make while acting on my behalf or on behalf of my estate.

Full Name

Your Signature for Photo Release

Select a date

Thanks for submitting!