Lipo-Light Consent and Release Form
Lipo‐Light Consent and Release Form
Name: (First) ______(Last)______DOB ______
Program and Background You have requested to be treated with the Lipo‐Light LED light therapy manufactured by Ward Photonics Inc. This treatment is the application of a 635nm of LED light, which has been shown through extensive research to cause the fat within the adipose (fat cell) to leave the cell and accumulate in the interstitial space around the cells, the LED light used for this treatment has no effect on tissue. Instead, the non‐invasive LED light helps the body break down fat by stimulating its biological function. Excess fat is then removed naturally by the body’s lymphatic system and subsequently excreted without the negative side effects and downtime associated with more invasive procedures such as liposuction. Any medical or cosmetic procedure carries risk, complications and varied results as to the effectiveness of a particular treatment. The purpose of this document is to make you aware of the nature of this product and its risks in advanced so that you can decide whether to go forward with this procedure. Procedure Initially you will consult with the therapist to determine if you are a candidate for the Lipo‐Light LED therapy. During this time you will have the opportunity to ask questions or voice concerns you may have regarding this treatment. If it is determined you are a candidate for this procedure, there will be a few preliminary steps consisting of: initial paperwork, measurements, pre and post treatment photos and suggested course of treatment. The treatment will be administered by placing the LED panel on the desired area(s) to be treated. It is recommended that a patient will need a minimum of 8 treatments for the Lipo‐Light LED therapy to achieve its desired effect. This treatment will be used in conjunction with a healthy diet and exercise. If you are not currently exercising, we will consult with you before beginning an exercise program to determine it is safe to proceed. Risks/Discomfort This treatment is non‐invasive and uses an LED Light paddle with 150 diodes. During treatment there should be no discomfort, the client will feel the warmth of the light and the tightness of the bands holding the paddles. If for any reason during treatment that the client feels discomfort due to the warmth of the paddles, paddles should be removed immediately. Client should report this discomfort to clinician immediately. If paddles are left on client after client has reported this discomfort, it is at the client’s own risk and provider assumes no responsibility. Lipo‐Light is suitable for anyone over 18.
Anyone suffering from the following would NOT be suitable for this treatment:
pregnant HIV – AIDS hepatitis C/D active cancer heart disease (not under the control of a physician) heart/pacemaker autoimmune disease (not under the control of/or monitored by a physician) thyroid problems (not controlled by medication)
Benefits Over the years the benefits of LED Light therapy have become more prominent. LED Light therapy has been used in many studies for pain management and recently by cosmetic surgeons to emulsify adipose before liposuction with FDA approval. The potential benefit of this treatment is body contouring without surgery. Problem areas or excess pockets of fat can be targeted, however the most commonly treated areas are the stomach, hips, flanks, and thighs. In clinical trials patients have averaged 2‐ 5cm lost from there stomach, hips, and thighs. These results do vary and no guarantee is implied or suggested that desired results will be achieved. Alternatives This is a strictly a voluntary cosmetic procedure. No treatment is necessary or required and the Lipo‐Light LED therapy has been chosen by the client. Questions By signing below, you certify that this procedure has been explained to you and your satisfaction. Any further questions can be directed to a Contouring therapist at this location. Consent I have reviewed this consent form. My consent and authorization for this procedure are strictly voluntary. By signing the informed consent form I grant authority for Northview Wellness Center to perform the described treatment. The purpose of this procedure, risks, complications, alternative methods of treatment have been fully explained to my satisfaction. Cosmetic indications for these procedures include but are not limited to cellulite reduction, treatment of problem fat areas, skin tightening, and skin rejuvenation. You may experience increased redness to the area for up to 12 hours. You will be able to return to normal activities following the treatment. Any photos taken will be used to show the clients progress and may be used in marketing ads. ______Initial
I have been informed of the potential risks and side effects of Lipo‐Light including but not limited to redness, swelling, heat sensitivity, pain, increase bowel movements and increased urination. The risks, potential damages and adverse side effects have been explained to me and I fully understand. ______Initial
I understand that a minimum of 8 OF TREATMENTS is required to achieve full results. At that point, I will be re‐evaluated to see if more sessions are needed in order to achieve realistic goals. Each body is different and may require more or less treatments depending on the clients diet, exercise, metabolism and body type. I understand the treatment is most successful if I also maintain a healthy diet and commit to an exercise program. I know that if after the treatment course I gain weight, the results of the Lipo‐Light may be reversed. ______Initial
No guarantee has been given by anyone as to the results that may be obtained by this treatment. I have read this informed consent and certify that I understand its contents in full. I have had enough time to consider the information and feel I am sufficiently advised to consent to this procedure. I herby give my consent to have this procedure. If at any time during the Lipo‐Light procedure I experience pain or discomfort of any kind, I agree to inform the staff immediately and/ or terminate the session at my discretion. The undersigned assumes all responsibility for behavior of self and their clients and agrees to abide by all Rules and Procedures of the property. The clients and all persons on the premises by invitation of the clients here by hold Northview Wellness Center, its employees, the corporation or any individual connected in any way to Healthy Weight Loss Solutions & Medical Spa harmless for any responsibility or liability for any accident, injury illness or damages sustained by or to any person or their personal property during their treatment appointments or use of facilities. Northview Wellness Center shall be indemnified and held harmless by the clients, and clients agree to pay all costs incurred in connection with any accident, injury illness or property damage loss, including attorney’s fees, regardless of how it may have occurred. The undersigned hereby releases and indemnifies Northview Wellness Center and holds harmless any employee, the corporation or any individual connected in any way to Northview Wellness Center for any loss of personal property and/or accident causing personal injury of any nature, including reasonable attorney’s fees and court costs in connection therewith.
Name: (First) ______(Last) ______Date ______
I further state that I am of lawful age and legally competent to sign this aforementioned release; I understand the terms herein is contractual and not a mere recital; I have signed this document of my own free act. At Northview Wellness Center we place the highest priority on the client’s right to privacy. Our office staff is trained to protect our private health information. We value your privacy, and are committed to maintaining your security and confidentiality in the use of any information you choose to share with us. We do not disclose identifiable information to any third party without your consent. Further, we do not sell, rent, or otherwise allow the unauthorized outside use of personal information such as names, addresses, phone numbers, or e‐mail addresses in our database without your permission. Copies of this form and signature will be valid as if original if this document is digitally scanned. I have explained the procedure, alternatives, and risks to the person or persons whose signature is affixed below. The patient has verbally communicated to me that they understand the contents of this form.
______Signature of Therapist Date______Northview Wellness Center
Weight Loss Intake Form
Your success is our #1 priority.
Help us to help you achieve that success by filling out this questionnaire as completely as possible.
Name: D.O.B. Date: _
Address: ______
Home #: Work #: Cell #:
Email: ______Height: Weight: Age: Sex:
Occupation: ______Favorite Hobbies:
Marital Status:______Do you enjoy your work? ______
Do you feel stress (explain)? ______
Are you currently under the care of a physician?
Do you exercise? How often? What type? ______
Are you interested in work out sessions with a personal trainer? Yes No
Do you get angry often? Are you happy (if not, why)? ______
What worries you most? ______
Are you interested in looking 5 to 10 years younger? Yes No
What do you expect from your Lipo-Light treatment? ______
Why did you choose us for Lipo-Light? ______
If you were referred by one of our former clients, please tell us who we can send a Thank
You note to: ______Weight Loss:
How long have you been overweight? ______
How much weight have you decided to lose? ______
How many times have you failed at weight loss? ______
What methods failed to help you lose weight? ______
Does your weight problem make you physically uncomfortable (explain)? ____
Does your excessive weight limit you and your activities (explain)? ______
How many times a year do you diet?
Do you suffer from uncontrollable cravings (explain)?
Do you feel out of control?
Do you eat because of emotions (explain)?
Are you embarrassed about your weight?
Is successful weight loss a top priority (explain)?
Will you purchase a new wardrobe when you lose weight?
What new activities will you become involved in after losing weight?
Are other members of your family overweight?
Briefly describe your eating behavior: ______
Do you believe weight loss has to be painful? ______
Do you believe weight loss can be enjoyable? ______
How fast do you want to be thin, trim, and fit? ______
Do you feel your eating behavior is normal? ______
Does your family support your weight loss efforts? ______
Does being overweight limit your social life? ______
Do you feel tired, run down, and out of energy? ______Can you remember being your ideal weight (explain)? ______
______
Has being overweight caused you pain and suffering (describe physical and emotional pain)? ______
Circle the most important element in deciding to use our services (circle one):
Effectiveness (your results)
Time (how fast you get results)
Service (how we respond to your needs)
Affordable (what we charge) HIPAA FORM
Introduction At Healthy Weight Loss Solutions, we are committed to treating and using protected health information about you responsibly. This Notice of Health Information Practices describes the personal information we collect, and how and when we use or disclose that information. It also describes your rights as they relate to your protected health information. This Notice is effective March 31th, 2003 and applies to all protected health information as defined by federal regulation.
Uses and Disclosures 1. We use your health information to document and plan treatment, progress, planning, etc. 2. We use your health information for payment. For instance, we need to send health information including procedures done and diagnoses to your insurance company. 3. We use your health information for regular health operations. For example, our compliance officer regularly chooses medical records for audits. This practice ensures that we are constantly working towards improved quality and effectiveness. 4. There are services provided in our organization through contacts with business associates. Examples include outside labs, x-ray, and transcription services. 5. We may use or disclose information to notify or assist in notifying a family member, personal representative, or other person responsible for your care, your location, and general condition.
The following are examples of other purposes for which Healthy Weight Loss Solutions is permitted or required to disclose confidential information without the individual’s written authorization. 1. Uses and disclosures for public health activities; 2. Reporting victims of abuse, neglect, or domestic violence; 3. Disclosures for judicial and administrative proceedings; 4. Disclosures for law enforcement purposes; 5. Uses and disclosures for cadaveric organ, eye or tissue donation purposes; 6. Disclosures to avert a serious threat to health or safety; and 7. Uses and disclosures for specialized government functions.
Separate Statements for Certain Uses or Disclosures Healthy Weight Loss Solutions may contact patients with appointment reminders, requests for the patient to contact Healthy Weight Loss Solutions for appointments, notices and letters concerning medical findings. Healthy Weight Loss Solutions may also contact the patient about treatments alternatives or other health related benefits and services that may be of interest to the individual. Effective Date of this notice is April 1, 2003; Updated April 10, 2008.
Individual Rights Although your health record is the physical property of Healthy Weight Loss Solutions, the information belongs to you. You have the right to: 1 The right to request restrictions on certain uses and disclosures of your information; 2 The right to revoke your authorization to use or disclose health information except to the extent that action has already been taken. 3 The right to receive confidential communications; 4 The right to obtain a copy or inspect your health information; 5 The right to amend protected health information; 6 The right to receive an accounting of disclosures of protected health information.
Healthy Weight Loss Solutions Center’s Rights 1. Healthy Weight Loss Solutions has 30 days with which to comply with a patient’s request to review or copy their health information. Healthy Weight Loss Solutions is allowed an additional 30 days if the record is off site. Healthy Weight Loss Solutions may charge a fee for copying the health record. 2. The physicians have the right to review the record and remove any information that they deem to be harmful to either the patient or to another individual; 3. The patient will be supervised by Medical Center staff during any review of the record. Supervision is allowed and required to prevent the removal or altering of the medical record. Healthy Weight Loss Solutions will charge staff time for this service.
Healthy Weight Loss Solutions Medical Center’s Duties 1. Healthy Weight Loss Solutions is required by law to maintain the privacy of confidential information and provide individuals with notice of its legal duties and privacy practices with respect to such information; 2. Healthy Weight Loss Solutions is required to abide by the terms of this Notice; and 3. Healthy Weight Loss Solutions reserves the right to change the terms of its Notice and to make the new Notice provisions effective for all confidential information that it maintains. Revisions to this Notice will be posted in the patient waiting area.
Complaints Individuals may complain to the Office Manager in writing to address above. You may also contact the Secretary of the U.S. Department of Health and Human Services at 200 Independence Ave., S.W.,Rm. 509F, HHH Building, Washington DC 20201. Further Information-Please contact the SMC administrator at 747-5861 for further information. I have received the Notice of Privacy Practices and I have been provided an opportunity to review it.
Name:______Date of Birth:______Signature:______Date:______Witness Signature (Check In)______Date:______