hereby authorize Active Body Wellness to perform a PHYSIQ treatment on me. I understand that this procedure may be used for many different areas of concern on the body, not limited to thighs, abdomen, buttocks and arms. I understand that I may require several treatments to obtain a significant, long-term results. I understand I may experience redness, dryness, mild to moderate sunburn sensation and/or soreness post-treatment. I understand all the potential side effects, as discussed with me prior to treatment. I understand that genetics, hormones, medication and skin color may interfere with the ability to perform an effective treatment. I commit to performing the post-treatment massage, with Physiq lotion, twice dally post-treatment, unless otherwise instructed by my provider.
The procedure may result in the following adverse experiences or risks:
- DISCOMFORT/PAIN - Some discomfort and/or pain may be experienced during treatment.
- REDNESS/SWELLING/BRUISING - Redness (erythema) or swelling (edema) of the treated area may occur. There also may be some bruising.
- HYPOPIGMENTATION / HYPERPIGMENTATION (Changes in skin color) - During the healing process, there is a possibility that the treated area may become either lighter (hypoplgmentation) or darker (hyperpigmentation) in color compared to the surrounding skin. This is usually temporary, but it may be permanent.
- BURNS / WOUNDS / BLISTERS - Treatment can result In burning or blisters of the treated area(s).
- INFECTION - Infection is a possibility whenever the skin surface Is disrupted, although proper wound care should prevent this. If signs of infection develop, such as pain, heat, or surrounding redness, please call our office at 602-358-8080.
- SCARRING - Scarring is a rare occurrence, but it Is a possibility if the skin surface is disrupted. To minimize the chances of scarring, it is IMPORTANT that you follow all post-treatment Instructions provided by our healthcare staff.
I acknowledge the following points have been discussed with me:
- Potential benefits of the proposed procedure, including the possibility that the procedure may not work for me
- Alternative treatments and my options
- Possible complications/risks involved with the proposed procedure and subsequent healing period
For women of childbearing age: By signing below I confirm that I am not pregnant and do not intend to become pregnant anytime during the course of treatment.
Photographic documentation will be taken. I hereby
authorlze the use of my photographs.