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Medical Consultation Form

Are you currently suffering or have you ever suffered from any of the following?

Urine infection
Medical Oedema
Kidney problems
Auto immune diseases
Pregnant, trying or breast feeding
Gastric Ulcers
Any form of infection or fever
Any condition already being treated by a practitioner
Use of alcohol or recreational drugs
Cardiovascular conditions
Thyroid problems
Any metal pins, plates or cosmetic implants
Dermatitis, keloid scarring or other skin issues
Muscular/Skeletal problems
Digestive Problems
Circulation Problems
Nervous System
Immune System
Gynecological Problems
Raynauds Syndrome

Lifestyle questions

Do you eat regular meals?
Do you smoke?
Are you on a diet?
How often do you exercise?
Do you suffer with hives or heat rashes?
Do you have any allergies? Are you allergic to Aspirin?
Do you take any supplements?
Have you had any major operations in the last 12 months?
Have you had any minor operations in the last 6 months?

I duly authorise the practitioners of Fab Clinics Loughborough Ltd to perform the procedure of Radiofrequency and Lipocavitation for the purpose of spot fat reduction/improving the appearance of cellulite/face and body skin tightening.


I am aware that clinical results may vary depending on individual factors,including medical history, client compliance with pre/post treatment instructions, and individual response to treatment.

I have been made aware that my diet and the amount of exercise I do will have a major effect on the results of my treatments.  If I do not make an effort to address my dietary requirements and exercise, I am aware that the results achieved may not be retained.


I understand this procedure involves a course of treatments, should I choose to go ahead after the trial treatment.


I certify that I am aware of the nature and purpose of the procedure, expected outcomes and possible complications, which are possible hives or rashes relating to the heat being used and I understand that no guarantee can be given as to the final result obtained. I am fully aware that my condition is of a cosmetic concern and that the decision to proceed is based solely on my expressed desire to do so.


I understand that it is my personal responsibility to inform the practitioner of the clinic named above of any changes to my medical history during the course of the treatment sessions for face or body areas.


I confirm that should this occur I shall advise the practitioner of any changes.

I consent to the taking of photographs and authorise their anonymous use for the purposes of medical audit,education and promotion.


I have fully read and understood the contents of this consent form.

I understand that the questions are given with regard to my safety and well-being.

I have answered all questions to the best of my knowledge and happy to proceed with the treatments.

Choose the treatments
Upload the picture
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