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Cavitation 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)
Kidney or liver disorder
Diabetes
High or low blood pressure
Epilepsy or seizures
Blood clotting disorders
Recent surgery in the treatment area
Hernia in or near treatment area
Skin infections or conditions in the treatment area
Use of anti-inflammatory or blood thinning medications
Any other health concerns:

Treatment Goals:

Have you had ultrasonic 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 Ultrasonic Cavitation is a non-invasive procedure designed to reduce localized fat deposits and improve body contour. I have disclosed all relevant medical history. I understand that results vary based on individual conditions and lifestyle habits, and multiple sessions may be required.


I acknowledge that this treatment is not a substitute for a healthy lifestyle, and I will maintain adequate hydration, nutrition, and activity level to support results.

Date
Month
Day
Year
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