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In order to conduct any and all cavitations services in our office, we must have proper consent forms in place. This will serve as your consent, awareness and validate your intent for these services. The initial consent form will serve for the first and all subsequent sessions. You will also be required to sign a paper copy of the same information just before your first session begins, which will serve as consent for all future sessions booked. 

 

If you elect to book without reading the consent/waiver info, you indicate that you take full responsiblity for outcomes and hold Mayberry Naturopathy LLC, Rutledge Wellness Clinic, LLC and any and all of it's respective staff and contractors harmless and not liable.

 

By reading and booking sessions, you acknowledge that all session fees as well as any yearly membership fees paid are non-refundable, regardless. 

 

 

HEAT CAVITATION/RADIO-FREQUENCY THERAPY CONSENT INFO

 

Disclosure. This treatment is a process and subsequent visits may be necessary in order to achieve the desired results. Subsequent visits are subject to additional charges per visit which depend on the amount of work needed. Actual results vary from person to person.Ultrasound Cavitation treatment carries with it possible health complications and consequences, which include but might not be limited to the risk to kidney. Liver, pacemaker static, birth defect, miscarriage, thyroid, ovaries, lactation complications, fat metabolism interference., pancreatitis, infection, scarring and/or allergic reaction to any products used, excessive thirst, dehydration, nausea. Patients who have pacemakers or active cancers may not qualify for these services. Skin redness and warmth are common in both cavitation and radio-frequency therapy. Most devices made an audible sound, heard through the duration of the session. Hydration is a vital part of empowering these therapies. Without hydration, the body cannot effectively remove all excess fat or inflammation being flushed from the body. I understand that I may not be eligible for these services if my skin is inflamed, infected, etc. 

 

Ultrasound Cavitation treatment includes, but is not limited to, the use of high-power low-frequency ultrasound cavitation which uses 40KHz frequency ultrasound to penetrate the skin and assist with the breakdown of fat cells by creating microbubbles that increase the pressure around the adipocyte and force it to implode, thus breaking down adipocyte’s cell membrane. After care instructions must be followed explicitly, whether given in writing or orally. Failure to follow instructions may compromise the final results of the treatment.

Radio frequency (RF) is a non-invasive heat treatment that helps tighten, increase collagen production, contour and refine deeper lines of the skin over the face and body. Both services can aid excess swelling and pain/inflammation.

Laser-lipo panel cavitation is a cold-laser therapy that interferes with the fat cell membrane, aiding the process of fat break-down for fat flushing.  

 

Before, during and after pictures or videos may be taken to document the treatment and are free from identification. These may only be used for legitimate business purposes.

 

I recognize that there are certain inherent risks associated with the above-described treatment and I consent to comply with the suggested number of sessions in order to achieve my goals. In exchange for such treatment, I hereby fully release and hold harmless Mayberry Naturopathy LLC, it’s agents, associates or staff during the course of my therapy and thereafter. I acknowledge that any I do not possess any serious health conditions, issues, etc. that would otherwise render me at risk for cavitation services.

I certify that I am not pregnant. 

Non-refundable payment for services are due at the appointment. By signing this agreement I confirm that I am over the age of 18. I understand that for conventional medical advice, I will consult a physician and that all procedures done in this office are non-invasive. This consent will represent the initial and all subsequent sessions of it’s type. 

 

FREEZING FAT TREATMENT CONSENT INFO

 

The Fat Freezing procedure uses a non-invasive vacuum applicator to draw in tissue and deliver controlled cooling at the surface of the skin. The procedure is for spot reduction of fat. It is a fat tissue contouring and is not the same as invasive liposuction via cosmetic surgeons. Mayberry Naturopathy LLC does not employ plastic surgeons and no such type of physician will provide therapy for today’s service. Someone who is overweight can expect to see less visible improvement than someone who has smaller fat deposits. Clinical studies have shown that Fat Freezing will naturally remove fat cells but, as with most procedures, visible results will vary from person to person. 

 

What you can expect: 

➢ The suction pressure may cause sensations of deep pulling, tugging and pinching. You may experience stinging, tingling, aching or cramping as the treatment begins. These sensations generally subside as the area becomes numb. 

➢ The treated area may look or feel stiff after the procedure and transient blanching (temporary whitening of the skin) may occur. You may feel a sense of nausea or dizziness as your body naturally warms and sensation returns to your treatment area. These are all normal reactions that typically resolve within minutes. 

➢ Bruising, swelling, and tenderness can occur in the treated area and it may appear red for a few hours after the applicator is removed.

➢ You may feel a dulling of sensation in the treated area that can last for several weeks after your procedure. Other changes including deep itching, tingling, numbness, tenderness to the touch, pain in the treated area, strong cramping, muscle spasms, aching and/or soreness- also have been reported after a Fat Freezing treatment. 

➢ Patient experiences will differ. Some patients may experience a delayed onset of the previously mentioned occurrences. Contact us immediately if any unusual side effects occur or if symptoms worsen over time. 

➢ You may start to see changes as early as three weeks after Fat Freezing, and you will experience the most dramatic results after one to three months. Your body will continue naturally to process the injured fat cells from your body for approximately four months after your procedure. 

➢ You may need additional treatments to reach your desired outcome. 

➢In rare cases, patients have reported hardness, discrete nodules or enlargement of the treatment area. 

I understand that these and other unknown side effects may also occur. 

 


Do you have any of the following? If so, please consult a physician for clearance before booking this appointment.

➢ Cryoglobulinemia or paroxysmal cold hemoglobinuria:  

➢ Known sensitivity to cold such as cold urticaria or Raynaud’s disease: 

➢ Impaired peripheral circulation in the area to be treated: 

➢ Neuropathic disorders such as post-herpetic neuralgia or diabetic neuropathy: 

➢ Impaired Skin sensation: Yes / No ➢ Open or infected wounds: 

➢ Bleeding disorders or concomitant use of blood thinners: 

➢ Recent surgery or scar tissue in the area to be treated: 

➢ A hernia or history of hernia in the area to be treated: 

➢ Skin conditions such as eczema, dermatitis, or rashes: 

➢ Pregnancy or lactation: 

➢ Any active implanted devices such as pacemakers and defibrillators:  

 

Pictures may be obtained for medical records. If pictures are used for education and marketing purposes, all identifying marks will be cropped or removed. 

Non-refundable payment for services are due prior or due at the appointment.

As with most medical procedures, there are risks and side effects. I understand that I may not be eligible for fat freezing if my skin is inflamed, infected, etc.. These have been explained to me in detail. I have read the above information, and I give my consent to be treated with Fat Freezing by the practitioners at Mayberry Naturopathy LLC and hold it’s owners, associates and staff harmless as I have been made aware of procedure details and expectations. This consent will represent the initial and all subsequent sessions of it’s type. 

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