LASER BODY SCULPTING

CONFIDENTIAL INTRODUCTION AND CONSENT

You have requested treatment with the ZERONA VZ8 LASER SYSTEM, a low-level laser manufactured by Erchonia Corporation.

This treatment involves the application of a 405 nm +/- 10 nm low-intensity laser designed for non-invasive body contouring. The Zerona VZ8 laser emulsifies adipocyte cells within the fat layer, facilitating the release of fat and lipids from these cells. Unlike high-power lasers used in other medical procedures, the Zerona VZ8 is a "cold" laser with no thermal effects on tissue.

The FDA has cleared ZERONA VZ8 LASER SYSTEM as safe and effective for circumferential reduction of the waist, hips, thighs, and other targeted areas. Although the procedure is safe and non-invasive, all medical or cosmetic treatments carry some risks, complications, and variability in effectiveness. The purpose of this document is to inform you about the nature of this treatment and any associated risks so you can make an informed decision.

During ZERONA VZ8 LASER SYSTEM treatments, there is no discomfort and you will not feel the laser, though the laser light will be visible. Risks associated with low-level laser therapy are minimal. The primary known risk involves potential damage to your eyes from prolonged exposure to laser light if unprotected. Protective eyewear will be provided when treatment is near the face and must be worn throughout the treatment.

Results of the ZERONA VZ8 LASER SYSTEM treatments may vary, and it is possible you may not experience improvements in body contour if you do not follow the recommendations provided by your practitioner or if you fail to disclose your complete lifestyle and medical history. This treatment reduces fatty content in fat cells but does not remove or destroy the cells themselves. Maintaining a poor diet, not exercising, or gaining weight after treatment may reverse your results, as fat can re-accumulate.

I understand this is an elective cosmetic procedure and that a prescribed series of treatments is required to achieve the desired outcomes. I recognize that the practice of medicine and aesthetics is not an exact science and acknowledge that no guarantees regarding treatment results have been made. I understand I must adhere to the recommended pre- and post-treatment guidelines outlined by CLT Laser Sculpting, LLC or Jaffe Chiropractic and staff, including:

CLIENT RESPONSIBILITIES

Stay hydrated (It is recommended to drink ½ your body weight in ounces every day. If you weigh 200 pounds you should be drinking 100 ounces of water each day)
Minimize consumption of alcohol, caffeine, and carbonated beverages
Maintain a healthy and balanced diet
Engage in regular, moderate exercise (e.g., daily walking)
Undergo lymphatic stimulation (massage, lymphatic drainage suit, vibration plate, etc.) as recommended

Failure to follow these guidelines may result in suboptimal outcomes.

No serious side effects or adverse reactions have been reported with the ZERONA VZ8 LASER SYSTEM. Your provider will perform a thorough assessment to determine if you are a suitable candidate.

Certain conditions MAY influence the efficiency of the Zerona VZ8 Laser treatment:

Contraindications:

Pregnancy *

Yes

Breast Feeding *

Yes

Photosensitive epilepsy *

Yes

Active cancer or within one year of remission

Yes

Treat with Caution:

Cardiovascular disease *

Yes

Blood thinners (anti-coagulants such as warfarin, aspirin) *

Yes

Kidney or liver diseases related to tumors *

Yes

Disease of the lymphatic system *

Yes

Pacemaker *

Yes

Today's Date:

First Name *

Last Name *

Preferred Name: *

Date of birth *

Address

Street Address

City

State

Postal code

Mobile *

Gender *

Female

Male

Other

Email *

Who may we thank for referring you or where did you find us? *

Employer

Occupation

Emergency Contact Name

Emergency Contact Number *

In order of importance, what are your “problem areas”? These are the areas that you want to work on. *

1.
2.
3.

Tell us about your goals for using laser body sculpting *

What is your current weight? *

What is your ideal weight? *

Tell us about your current state of health and how you feel it is keeping you from living life like you want *

Do you feel you are currently in "Good Health"? Yes or No. please explain *

What have you tried up until now to get results? *

What have you noticed worked? *

What have you noticed did not worked? *

Tobacco use *

Yes

If yes for tobacco, how many packs per day and for how many years?

Alcohol use *

Yes

If yes for alcohol use, how many drinks per week?

If yes for caffeine, how many cups per day?

Water intake, how many ounces per day? *

How many meals per day? *

Describe your typical breakfast? *

Describe your typical lunch? *

Describe your typical dinner? *

Describe your typical snacks? *

Salt intake *

Low

Medium

High

Sugar intake *

Low

Medium

High

Do you exercise regularly? *

Yes

What is the intensity of your exercises? *

Low

Medium

High

None

What type of exercises? *

How many hours of sleep do you get per night? *

List of current or indicate that you will bring a list to your initial appointment. Type none if not currently taking any medications. *

List of current vitamins & supplements you take on a regular basis. Type none if not currently taking any. *

Is there anything you would like us to know?:

I consent to allow the staff of CLT Laser Sculpting or Jaffe Chiropractic to speak with me and perform an evaluation (if necessary) in order to determine if I am a good candidate for the non-surgical Laser Assisted Weight Loss/Fat Loss. The questions on this form have been answered completely and truthfully to the best of my knowledge. I hereby consent to undergo the Zerona VZ8 Laser treatments.

Full Name

Date Signed

Signature:

Clear