Complete our Consent Form

To ensure LEMONBOTTLE remains professional and compliant, every LEMONBOTTLE patient needs to submit a consent form before the product is administered.

LEMONBOTTLE Consent Form

Submitting this consent form before you receive the LEMONBOTTLE Booster, is compulsory

Please complete the form below, or download the Consent Form and email it to info@lemonbottle.co.za when completed.

PERSONAL INFORMATION

MEDICAL HISTORY

I REQUEST THE FOLLOWING LYPOSIS PROCEDURES

Please confirm the information provided is true and correct by typing your full name and date into the box below:

APPROVAL & CONSENT OF PROCEDURE

By ticking the boxes you will agree to the subsequent statements.:

I hereby acknowledge that the Lypolysis I will receive at the salon (as completed above) and performed by the therapist (as completed above), a Lemonbottle trained technician, are voluntary and I agree to the procedure out of my own free will. I fully understand that the Lypolysis procedure is for cosmetic purposes only and should not be construed or be intended for any medical treatment and/or plastic surgery.

Accordingly I hereby acknowledge that I fully understand and have been given sufficient opportunity for discussion to have any questions answered about the Lypolysis procedures to be performed by my therapist (as completed above).

I understand and acknowledge that this procedure is a process, and additional appointments after the initial procedure is necessary in order to achieve the desired results and will be subject to charge at additional rates. I understand the treatment procedures and accept the risks. Lemonbottle products and technicians will at all times maintain acceptable high standards and procedures and will endeavor to provide the best possible result. I do however acknowledge and understand that my therapist cannot predict the results in advance and that no guarantees have been made to me concerning the results of this procedure.

I acknowledge further that I have received adequate information to give my informed consent and authorise the therapist to perform all Lypolysis procedures listed. In the event that I may have additional questions or concerns regarding my treatment, I will consult Lemonbottle and or its therapists immediately. I also hereby grant my consent for Lemonbottle to use any or all before and after photos taken of the Lypolysis procedures conducted by Lemonbottle for record purposes, and further give my permission to use any reproductions or adaptations of the photos for publicity, or other purposes. This might include (but is not limited to) the right to use them in printed and online publicity, social media, press releases and advertising applications.

I confirm that I declared all known allergies, prescription medication, conditions, treatments or products I am currently ingesting or using topically and agree to follow the pre-and post-procedure instructions I received and will strictly adhere to such instructions. I understand that my failure to do so may compromise my changes for a successful procedure. I will not hold Lemonbottle and/or therapist responsible for any of my conditions that were present, but not disclosed at the time which may be affected by the procedures performed. I understand that withholding information or providing misinformation may result in contraindications and/or irritation for the procedures received.

I confirm further that I have received, read and understand the above paragraphs, client card, pre-and post after care and consent form. I have had it explained to me and understand that ticking this box and submiting this form online, indicated my agreement to all of the conditions and provisions stated in this document.

INDEMNITY - By signing this agreement, I hereby indemnify and hold harmless Lemonbottle, its employees, agents or any other person related to and or trained by them, or any damage or harm that may arise out of any procedure performed by them to me, whether such injury or damage or loss is caused by the negligence, acts or omissions or Lemonbottle or any of its employees or agents or by any other cause whatsoever.

Date:

Time:

Full Names and Surname

To ensure LEMONBOTTLE remains professional and compliant, every LEMONBOTTLE patient needs to submit a consent form before the product is administered.

LEMONBOTTLE Consent Form

Submitting this consent form before you receive the LEMONBOTTLE Booster, is compulsory

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