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Aqualyx Consent Form

Please fill out the following form
in order to participate in our activity.

I have read this information and certify that I understand its contents in full. I have been informed that I must not apply any kind of cosmetics onto the treated area within the first twelve hours following the treatment with AQUALYXTM and that immediate exposure to heat sources during the following days are to be avoided (e.g. sunlight, UV-radiation, sauna). I am aware of the fact that after therapy with AQUALYXTM, treatments using laser, cryolipolysis or radio-frequency therapy must not be administered. Furthermore, I should abstain from particularly demanding physical exercise for seven days. I have been given a copy of this information. My consent and authorisation for this procedure is strictly voluntary. By signing this informed consent form, I grant authority to my practitioner to adminster AQUALYXTM. The nature and purpose of this procedure, with possible alternative methods of treatment as well as complications, have been fully explained to my satisfaction. No guarantee has been given by anyone as to the results that may be obtained by this treatment. I have had enough time to consider the information from my practitioner and feel that I am sufficiently advised to consent to this procedure. I hereby give my consent to this procedure and have been asked to sign this form after my discussion with the practitioner.
cardiac pacemakers, implanted defibrillators, implanted neurostimulators
drug pumps
pulmonary insufficiency
malignant tumor
Fever
sensitivity or allergy to latex
haemorrhagic conditions
anticoagulation therapy
heart disorders
epilepsy

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