COOL MICROWAVE CONSULTATION & CONSENT FORMΔPlease complete this form accurately. The information helps us determine whether treatment is appropriate and how it can be performed safely.1.CLIENT INFORMATIONFull Name Age Phone Number Email Emergency contact Emergency phone 2. TREATMENT INFORMATIONTreatment area(s) Treatment date Primary concern/goal: Number of session Previous body-contouring treatments Date of last treatment 3.SAFETY SCREENING/CONTRAINDICATIONS Please select Yes or No for every question and provide details for any “Yes” response.Are you pregnant or breastfeeding? Yes NoDetails/date Do you have a pacemaker or another implanted electronic device? Yes NoDetails/date Do you have cancer, or are you currently undergoing cancer treatment? Yes NoDetails/date Do you have any metal implants, especially near the proposed treatment area? Yes NoDetails/date Do you have diabetes, heart disease, or severe vascular disease? Yes NoDetails/date Are you currently taking anticoagulant or blood-thinning medication? Yes NoDetails/date Are there any wounds, infections, rashes, inflammation, or impaired skin in the treatment area? Yes NoDetails/date Have you recently undergone dermal filler, Botox, or another energy-based treatment in or near the treatment area? Yes NoDetails / date 4.ADDITIONAL HEALTH INFORMATIONCurrent medications and supplements: Allergies or sensitivities: Relevant medical conditions or previous surgeries: 5.CLIENT CONSENTI confirm that the information provided on this form is complete and accurate. I understand that Cool Microwave is a non-invasive body-contouring treatment that uses controlled energy to target tissue in the selected treatment area. I understand that individual responses and results vary and cannot be guaranteed. Possible temporary reactions may include warmth, redness, tenderness, swelling, bruising, numbness, tingling, or discomfort. I agree to follow all pre-treatment and post-treatment instructions and to inform the practitioner immediately of any unusual or persistent reaction. I understand that the practitioner may postpone or decline treatment if a contraindication or safety concern is identified. I have had the opportunity to ask questions and received satisfactory answers. Yes Novoluntarily I voluntarily consent to receive Cool Microwave treatment at NB MedSpa.I consent to treatment photographs for my confidential client record: Yes NoI separately consent to de-identified photographs being used for marketing: Yes Nodeclare I declare that all information provided by me in this form is accurate and complete. Any omission, concealment, or incorrect information is solely my responsibility, and I release Zia Cosmetic Clinic and its staff from any liability arising from such inaccuracies.Submit Form
