Vanquish Client Intake Form

GENERAL PATIENT RECORD

Patient's Name

Date of Birth

Age

Phone

Email

TREATMENT CONSIDERATIONS

You are scheduled for a series of non-invasive treatments with the BTL VANQUISH ME.
Check the following boxes if you agree:

Initial

BTL VANQUISH ME is designed for reduction of abdominal and thigh circumference by disruption of adipocyte cells by mean of high frequency electromagnetic field.

Initial

Your treatment provider will discuss your specific treatment needs. The recommended number of treatments is 4. The treatment is typically about 45 minutes per session, with sessions separated by 7-10 days. You may need additional treatments depending on the severity of your condition. For optimal results, it is important to follow the treatment plan that has been established for you. The results will typically continue to improve over the next few months.

Initial

Please arrive at your appointment well hydrated. Ideally, you should hydrate 2 days before, on the day of the treatment, and 4 days after the treatment. This will result in a more comfortable and efficacious treatment.

Initial

On the day of the treatment, you are advised to wear comfortable clothing so the treatment area can be easily accessed. You will be asked to remove any jewelry from the area of interest.

Initial

I acknowledge that successful treatment outcome can be affected by smoking or excessive alcohol consumption, as well as: eating disorders, on-going medication or insufficient hydration. While no special diet is required, you are encouraged to eat healthy to help promote and maintain results.

Initial

There is typically no pain associated with your treatment and there is no anesthetic required. You will experience an intense heat sensation, but not pain and moderate erythema (redness) in the treated area which may last for a few hours post therapy. The procedure doesn’t require any recovery time. Typically, you can get back to your daily routine right after the treatment.

Please answer whether you currently have or have had any of the following:

Implanted electronic devices such as a cardiac pacemaker, bladder stimulator, spinal cord stimulator or electrodes for a myoelectric prosthesis

Yes
No

Metal-containing IUD

Yes
No

Hemorrhages or risk of hemorrhage

Yes
No

Septic conditions and empyema

Yes
No

Malignant tumors and undiagnosed tumors

Yes
No

Implants, areas where implants have been removed or metal inclusions

Yes
No

Implants that could be impaired by electromagnetic field

Yes
No

Thermohypesthesia or thermohyperesthesia

Yes
No

Acute inflammations, swellings that still feel warm

Yes
No

Severe arterial obstructions (stage III and IV), arterial disease

Yes
No

Gynecological disorders involving acute inflammation

Yes
No

Wetness or perspiration

Yes
No

Permeating irradiation of the thorax in cases of severe heart diseases

Yes
No

Sudeck’s syndrome (stage I and II)

Yes
No

Basedow’s disease (irradiation could cause serious states of agitation)

Yes
No

Varicose veins, varices, deep vein thrombosis, phlebitis

Yes
No

Cardiac conditions, circulatory insufficiency

Yes
No

Occlusive vascular disease, ischemic tissues in individuals with vascular disease

Yes
No

If you answered YES to any of these questions, please specify:

For the full range of contraindications, warnings and cautions, consult your treatment provider.

Initial

I am aware that pregnancy and nursing are contraindicated, and pregnant women can’t undergo the treatment. I should not undergo the treatment when menstruating; there is possibility of increased menstrual flow.

Initial*

I understand that there are certain risks associated with BTL VANQUISH ME treatments and they include but are not limited to: erythema, burns due to excessive exposure, reduced thermal sensation, hypersensitive skin, impaired blood flow, and moisture in the treatment area.*

Initial

I understand that the treatment may involve risks of complications or injury from both known and unknown causes, and I freely assume these risks.

Initial

I understand the results may vary from person to person and that an exact result cannot be predicted. Completing a full treatment series is necessary to maximize treatment efficacy. It is very unlikely, but it is possible that you will not feel any recognizable result after the procedure. I acknowledge the results may not meet my expectations.

Initial

I certify that I have read this entire document and that I agree with all provisions. I certify that I have had the opportunity to ask questions and these questions have been answered in full to my satisfaction. I fully understand the treatment conditions, the procedure and possible side effects.

Initial

I have read the above information, and I request and give my consent to be treated with the BTL VANQUISH ME by the physician(s) in this practice and his/her designated staff.

Patient's Signature

Date

Witness' Name

Witness' Signature

Date

Practice Name

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Please answer whether you currently have or have had any of the following:

If you answered YES to any of these questions, please specify:

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