Health & Fitness Questionnaire
TORC BODY CANCELLATION & APPOINTMENT RESCHEDULE POLICY
This consent form is designed to provide a written confirmation of such discussion by recording some of the more significant medical information given to you. It is intended to make you better informed so that you may give or withhold your consent to the proposed procedure(s).
I understand that this treatment is not used to treat medical conditions nor does this treatment claim or guarantee relief of any medical conditions.
Risk/Benefits of Proposed Procedure(s)
Just as there may be benefits to the procedure(s) proposed, I also understand the procedure involves risks. These risks include allergic skin reaction, redness in the treatment area, irritation and swelling. In a state of dehydration, nausea may occur. It might also increase my heart rate.
I have read the contraindications of the TORC device. I’ve shared my true medical conditions and medical history. I am in a healthy condition to use the device. I do not have epilepsy, paralysis, Parkinson’s disease. I am not pregnant. I do not have metallic implants in my body including pacemaker.
I have been explained the protocol and procedure of the TORC Body system. I understand that each person has a different response time. The potential benefits and risks of the proposed procedure(s), and the likely result with such treatment, have been explained to me. I understand what has been discussed with me as well as the contents of this consent form, and have been given the opportunity to ask questions and have received satisfactory answers.
Consent to Procedure(s) and Treatment
I voluntarily give my authorization and consent to the performance of the procedure(s) described above. Should any discomfort occur during the treatment, I will discontinue the session after immediately notifying the technician of any unusual sensations or skin reactions. I will not hold Esteem Esthetics liable for any skin related irritation or resulting effects of thermal heat being applied during treatment.
Payment Terms & Conditions
Payment for TORC procedures are due in advance of treatment sessions and are non-refundable.