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RF Vacuum Treatment

Please Fill out this Form

Date of Birth:
Month
Day
Year

Medical History:

Please check any that apply:
Pregnancy or breastfeeding
Heart condition or pacemaker
Metal implants or surgical mesh in the treatment area
Cancer (past or present)
Diabetes
High or low blood pressure
Skin conditions (eczema, psoriasis, etc.)
Epilepsy or seizures
Blood clotting disorders
Recent surgery in the treatment area
Hernia in or near treatment area
Current use of medications that thin the blood or affect skin sensitivity
Any other health concerns:

Skin & Body Information:

Have you had RF, cavitation, or other body contouring treatments before?
Yes
No
Do you have any tattoos, scars, or piercings in the treatment area?
Yes
No
Are you currently using any skincare products with Retinol, AHAs, or BHAs?
Yes
No

Lifestyle Information:

Are you currently following any specific diet plan?
Yes
No

Consent & Acknowledgment:

I understand that RF Vacuum Treatment is a non-invasive aesthetic procedure that involves radio frequency energy and vacuum suction. I have disclosed all relevant medical history. I understand that individual results vary, and multiple sessions may be necessary. I understand that hydration, healthy diet, and physical activity are essential to achieving and maintaining results.


I acknowledge that this treatment is not a substitute for medical care or weight loss. I have had the procedure explained to me and all my questions answered.

Date:
Month
Day
Year
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