CoolSculpting – Treatment Consent Form

I understand that I will have a consultation for the procedure(s) recommended to me and the risks associated with the procedure(s) and I give my consent to be evaluated for the procedure(s) recommended and discussed by my healthcare provider, Andre Bonnet MD, PC. associated healthcare providers, and staff. I will review and sign the procedure consent form prior to undergoing the procedure(s). As with most procedures, there are risks and side effects and these will be explained to me in detail. My signature below acknowledges that I have read and understand the content of this informed consent document. Results vary from person to person. Additional treatments may be necessary to achieve my desired outcome. Although highly unlikely, it is possible that I may not experience any noticeable result from the procedure(s). I understand that I will sign a separate consent form for the procedure(s) prior to undergoing the procedure(s). I agree to follow up at the recommended interval advised at the time of my procedure(s) and to contact Andre Bonnett MD, PC or the provider who treated me and/or Sculptology and advise of any change in my condition or any problem I may experience. I understand that this is a consultation for an elective procedure and I hereby voluntarily consent to this consultation for the treatment. My questions have been answered satisfactorily. I certify that if I have any changes in my medical history, I will notify the healthcare professional who treated me immediately. I understand that the procedure(s) is an elective procedure performed solely for cosmetic purposes and is not critical to my health. I assume all risks as my own and agree to hold harmless, Andre Bonnett MD, PC and Dr. Bonnett’s providers and/or associates, Sculptology Pleasanton, LLC, and Sculptology Management, LLC, its providers, staff members, affiliates, from any and all liability, damages, causes of action, allegations, suits, sums of money, claims and demands whatsoever unless arising from their gross negligence. I agree to the consultation for the treatment on my own free act. By signing below, I agree to proceed with the consultation for the procedure(s) and am providing my informed consent.