Skip to content
Gift Cards
Book Here
MENU
About
Videos
Services
Hair Removal
Injectables and Fillers
Face & Body Rejuvenation
PRP Face & Hair Restoration
Alternative Services
Sexual Wellness
Weight Loss
Fractional Laser
Vitamins
Specials
Products
Gift Cards
Cart
Checkout
Franchise
Financing
Forms
New Client Paperwork
Client Information & Medical History
Consent to Treatment
COVID-19 Consent Form
HIPPA Medical Information Release Form
The Natural Place Medical Spa: VIP Membership Agreement
Alternative Services
BEMER Mat Therapy & Consent Form
LED Teeth Whitening Informed Consent Form
Ioncleanse Foot Bath Release Form
Spray Tan Consent
Lash and Brow Tinting Intake
Waxing Consent
Face & Body Rejuvenation
Cosmelan Consent Form
Facial Services Client Informed Consent Form
Pixel 8 Fractional Laser Resurfacing Consent
Sclerotherapy Consent Form
Spectrum Laser System Tattoo, Vein, Laser Hair & Erbium Yag Laser Consent Form
Ultralight Consent Form
Vein Go Consent Form
Viora RF Face Consent
DermaSweep / Microdermabrasion Informed Consent
Dermaplaning Consent Form
Informed Consent for Hydra Facial
Chemical Peels Consent
Medical Strength Peels Client Informed Consent Form
Fractional Laser
Carbon Laser Facial Consent Form
CO2 Fractional Laser by Phoenix
Melasma
Toe Nail Fungus Treatment By LASER
Hair Removal
Hair Removal by Laser Consent
Hair Removal by Electrology Consent
Injectables And Fillers
Informed Consent for Injectable Treatment
Botox (Botulinum A Toxin), Jeaveau and/or Xeomin Informed Consent
Informed Consent for Belotero
Radiesse® Injectable Informed Consent
PRP Face & Hair Restoration
PRP, Face, Neck, Chest, Hands, Hair Restoration or Eyebrow Consent
Sexual Wellness
Breast Cupping / Stimulation Consent Form
RejuVanate C02 Vaginal Rejuvenation
THERMISMOOTH® Consent
ThermiVA Consent
Vitamins
IV Therapy Consent Form
Weight Loss
Body Tone Muscle Micro Current & Re Growth Device Consent
Cellulite & Body Contouring Treatments Viora/ Diamond/ Ultrashape Power Informed Consent
Fit Body, IR & Salt Cave & Full Body LED Consent Form
Whole Body Vibration Consent
Diamond Laser Lipo Consent
Lymphatic Drainage by Pressotherapy
Other Forms
CryoClear® Consent & Release
Consent Light / Energy Based Laser Treatment
Filler Consent By All Methods
Informed Consent for Laser and Other Services
Jeuveau
Mesotherapy Consent Form
Photofacial/Skin Rejuvenation and/or Non-Ablative Wrinkle Reduction
Pico Lazer Consent Form
Memberships
Locations
Broomfield, CO
TX COMING SOON
Contact
Pressotherapy Treatment Consent Form
Pressotherapy Treatment Consent Form
Kyle Gordon
2023-07-17T20:53:21-06:00
Pressotherapy treatment Consent Form
Patient Name
First
Last
Email
The Zemits Pressotherapy Treatment is a non-invasive treatment. It uses a pressotherapy suite to compress the skin tissues. The procedure is for improving the skin tone, blood and lymphatic circulation, improves the appearance of cellulite and reduces circumferences and that it may also be therapeutic for improving circulation and muscle aches in the treated areas. It is not a weight-loss solution and it does not replace traditional methods such as liposuction. Initial: I duly authorized Zemits Pressotherapy Treatment on me. I understand that: Pressotherapy is a compression technique designed to improve overall circulation and tone the circulatory system for faster detoxification and elimination, fluid clearance, helping slimming and firming, toning and oxygenation. A computer-controlled pump inflates the individual sections of the multi chambered garment, which are positioned around the limbs. The pump inflates each chamber of the garment individually. I understand I should avoid Pressotherapy if I have any of its contraindications such as: infection, open wound, asthma, blood clots, first trimester of pregnancy, history of miscarriages, severe eczema, deep vein thrombosis, cardiac heart failure, or pacemaker. The Zemits Pressotherapy is a device used for improving the appearance of cellulite and reducing circumferences and that it may also be therapeutic for improving circulation and muscle aches in the treated areas. I understand there is a possibility of short-term effects such as discomfort, reddening, and temporary bruising. These effects have been fully explained to me.
Initial Here
I understand that: Clinical results may vary depending on individual factors, including but not limited to the medical history, skin type, patient compliance with pre- and post-treatment instructions, and individual response to treatment. These effects have been fully explained to me (patient initials) Pressotherapy Treatment involves a series of treatments and the fee structure has been fully explained to me.
Initial Here
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 based solely on my expressed desire to do so.
Initial Here
I confirm that I have been informed regarding any current or past medical condition, disease or medication taken. I consent to the taking of photographs and authorize their anonymous use for the purposes of medical audit, education and promotion. I certify that I have been given the opportunity to ask questions and that I have read and fully understand the context of this consent form.
Initial Here
Do you have any of the following?
Deep vein thrombosis
Yes
No
Acute infection of limbs
Yes
No
Heart Failure
Yes
No
Asthma
Yes
No
1st trimester pregnancy
Yes
No
Severe eczema
Yes
No
Epilepsy
Yes
No
Emphysema
Yes
No
Pacemaker
Yes
No
Hypothyroidism
Yes
No
Presence of pain
Yes
No
Numbness / loss of sensation
Yes
No
Hemophilia
Yes
No
High blood pressure
Yes
No
Coumadin
Yes
No
Pregnancy or lactation
Yes
No
Crohn’s Disease
Yes
No
Hyperthyroidism
Yes
No
Infection in the urinary system i.e., kidneys, bladder and urethra
Yes
No
Signature
Page load link
Go to Top