Pressotherapy treatment Consent Form

Patient Name
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.
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.
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.
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.

Do you have any of the following?

Deep vein thrombosis
Acute infection of limbs
Heart Failure
1st trimester pregnancy
Severe eczema
Presence of pain
Numbness / loss of sensation
High blood pressure
Pregnancy or lactation
Crohn’s Disease
Infection in the urinary system i.e., kidneys, bladder and urethra