Lipofirm Consent Form

I duly authorise the practitioners to perform the Lipofirm procedure for the purpose of spot fat reduction / improving the appearance of cellulite/face and body skin tightening. I am aware that clinical results may vary depending on individual factors, including medical history, client compliance with pre/post treatment instructions, and individual response to treatment.I have been made aware that my diet and the amount of exercise I do, will have a major effect on the results of my treatments. If I do not make an effort to address my dietary requirements and exercise, I am aware that the results achieved may not be retained.

I understand the treatment involves a course of treatments. The fee structure has been fully explained and I understand that I am required to pay for a course of treatments prior to any procedures taking place. I am fully aware that should I wish to cancel the course the outstanding treatment value is non refundable.


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 a cosmetic concern and that the decision to proceed is based solely on my expressed desire to do so.

I understand that it is my personal responsibility to inform the practitioner of the clinic named above of any changes to my medical history during the course of Lipofirm Pro treatment sessions for face or body and I confirm that should this occur I shall advise the practitioner of any changes.

I consent to the taking of photographs and authorise their anonymous use for the purposes of medical audit, education and promotion. Delete if preferred.

I certify that I have been given the opportunity to ask questions, any questions have been answered to my satisfaction and that I have fully read and understood the contents of this consent form. I understand that these questions are given with regard to my safety and well-being. I have answered all questions to the best of my knowledge and happy to proceed with Lipofirm Pro treatments for face and body.

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