Intake Forms

Patient Details

This Form is for MedWave™ Treatments

Intake Checklist for MedWave

Please check all that apply:

Medications and Treatments

Specific Risks and Concerns

Acknowledgment of Risks

Consent for MedWave RSA to use my results for marketing and promotional purposes

Legal Waiver and Consent

By submitting this form, I acknowledge that I have read and fully understand the potential risks and contraindications associated with red light therapy (635nm) and vibration therapy. I certify that:

1. I have disclosed all relevant medical conditions, medications, and treatments as requested in this form.
2. I understand that red light and vibration therapy may have side effects, including but not limited to skin irritation, muscle soreness, dizziness, or interactions with my current medications or conditions.
3. I agree to use this equipment voluntarily and assume full responsibility for my own health and safety during the therapy sessions.
4. I agree that there are no refunds allowed.

I hereby waive, release, and hold harmless MedWave RSA, its employees, contractors, and affiliates from any and all claims, liabilities, or damages arising out of or in connection with my use of the equipment and therapy sessions.

This waiver and release of liability apply to all past, present, and future sessions unless revoked in writing.

Patient Details

This Form is for Vibration Plate & Photobiomodulation

Intake Checklist for Vibration Plate AND Photobiomodulation...

Please check all that apply:

General Health Conditions Where Vibration Plate is Contraindicated

General Health Conditions Where Vibration Plate is Contraindicated Unless Cleared by Treating Medical Practitioner in Writing

General Health Conditions Where Caution should be exercised and intensity decreased for initial Vibration Plate sessions.

Medications and Supplements

Other medications or supplements currently used (Include Name & Dose):

Intake Checklist for ONLY Photobiomodulation...

Please check all that apply:

General Health Conditions

Acknowledgment of Risks

Consent (your details) to use my results for marketing and promotional purposes

Legal Waiver and Consent

By submitting this form, I acknowledge that I have read and fully understand the potential risks and contraindications associated with red light therapy (635nm) and vibration therapy. I certify that:

• I have disclosed all relevant medical conditions, medications, and treatments as requested in this form.
• I understand that red light and vibration therapy may have side effects, including but not limited to skin irritation, muscle soreness, dizziness, or interactions with my current medications or conditions.
• I agree to use this equipment voluntarily and assume full responsibility for my own health and safety during the therapy sessions.
• I agree that there are no refunds allowed.
• I hereby waive, release, and hold harmless (your details) , its employees, contractors, and affiliates from any and all claims, liabilities, or damages arising out of or in connection with my use of the equipment and therapy sessions.
• This waiver and release of liability apply to all past, present, and future sessions unless revoked in writing.

Patient Details

This Form is for Lipolysis Injections.

NB: If you are insulin dependent and allergic to Soy and peas you are not suitable for Lipolysis

Treatment Description

Lipolysis injections involve the administration of approved fat-dissolving agents into localized areas of subcutaneous fat. These agents work by breaking down fat cells, which are then metabolized and eliminated by the body over time. This treatment is not a weight-loss solution but a body-contouring procedure.

Expected Results

• Results are gradual and may take several weeks.
• Multiple sessions may be required.
• Results vary per individual.
• No guarantee of specific results.

Possible Side Effects & Risks

• Swelling, redness, bruising, tenderness or pain.
• Burning, itching, temporary numbness.
• Hardness or nodules under the skin.
• Uneven results, infection or allergic reaction (rare).

Contraindications

I confirm that I am not pregnant or breastfeeding and do not suffer from undisclosed medical conditions such as liver or kidney disease, autoimmune disorders, active infections, bleeding disorders, or known allergies.

No Guarantee Statement

I understand that results cannot be guaranteed and that maintenance of results depends on lifestyle choices.

Indemnity & Consent

I voluntarily consent to lipolysis injections and release and indemnify TheraGlow, its practitioners and staff from any claims or liabilities, except in cases of proven negligence. I confirm that all my questions have been answered to my satisfaction.