Body Tone Informed Consent Agreement-Top Beauty Bar

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Please review the consent. I have read, and acknowledge these requirements. It will automatically return to the provider upon completion.

Body Tone

  • I understand that the device being used for muscle tone improvement of which I am consenting to be a patient receiving tone treatment.

  • I understand that clinical results may vary depending on individual factors, including but not limited to medical history, skin type, patient compliance with pre- and post-treatment instructions, and individual response to treatment.

  • I understand that there is a possibility of short-term effects such as reddening, mild burning, pain, swelling, muscles spasm, and temporary discoloration of the skin, as well as the possibility of rare side effects such as treatment area infection, scarring and permanent discoloration.

  • I understand the treatment with this system involves a series of treatments and the fee structure has been fully explained to me.

  • I certify that I have been fully informed of the nature and purpose of the procedure, expected outcomes and possible complications, and I understand that no guarantee can be given as to the final result obtained.

  • I am fully aware that my condition is of cosmetic concern and that the decision to proceed is solely based on my expressed desire to do so.

  • I confirm that I have informed staff regarding any current or past medical conditions, disease or medication taken.

I have read, and acknowledge these requirements of the procedure. 

Medical Waiver

I have read, and acknowledge these requirements, of my procedure to better assist with treatment adversities that can occur if a protocol is not taken seriously. I know that this is an elective service and my questions regarding services have been answered satisfactorily I understand this procedure and accept all risks and will notify Top Beauty Bar of any changes that could put my treatment at risk.

I take full liability and responsibility for all risks, undesired outcomes, or adverse events associated with the injections and will not hold the provider of Top Beauty Bar LLC liable for any unfavorable outcome or adverse event. I release Top Beauty Bar LLC, its owner, and medical staff from liability associated with the procedure. This consent form is freely and voluntarily executed and shall be binding upon my spouse, relatives, legal representatives, heirs, administrators, successors, and assigns. I hereby release Top Beauty Bar LLC, Tina Videtic, and staff from all liabilities associated with the indicated procedure. The procedures to be used to treat my condition have been explained to me. Any adverse reaction should be reported immediately to the office mobile at 920-678-7709.

I have read, and acknowledge these liability requirements of my procedure.

Do you consent to the area treated of photos posted online?
Review & Agree