Consent Form - Midland Contour Clinic

Type of Treatment

Full Name *

Email Address *

Contact Number *

Date of Birth

Have you had any previous Cosmetic Surgery *YesNo

Date of Surgery

Name of Surgeon:

Name and Location of Surgical Facility:

Was your surgery performed domestically or abroad *Domestic (within the country)Abroad (outside the country)

Have you received post-operative clearance from your surgeon to begin lymphatic drainage massage *YesNoPending

Are you currently under the care of any other healthcare providers for post-surgical care? *YesNo

Yes (please specify):

Please indicate if you have or have had any of the following:Blood Clots or Deep Vein Thrombosis (DVT)Infection or Open WoundsCardiovascular ConditionsKidney or Liver DiseaseLymphedema (pre-existing)DiabetesAutoimmune DisordersOther (please specify):

Please specify

Do you suffer from Cancer or Chron's disease? *YesNo

Do you have any cold or flu symptoms? *YesNo

Please Specify

Do you have Oedema (fluid retention in the body)? *YesNo

Do you take any immunosuppression medication (an act that reduces the activation or efficiency of the immune system)? *YesNo

Please Specify

Do you have any active infections? *YesNo

Please Specify

Do you suffer from severe hypertension (high blood pressure)? *YesNo

Do you suffer from Hyperlipidemia (raised serum levels of one or more of total cholesterol) *YesNo

Do you suffer from Diabetes? *YesNo

Diabetes TypeType 1Type 2

Are you pregnant? *YesNo

Are you breastfeeding? *YesNo

Do you have any Lymph nodes and joints cannot be treated with cavitation? *YesNo

Please specify

Are you on your menstrual cycle? *YesNo

Do you have any skin allergies or inflammation? *YesNo

Please specify

Do you have any metallic implants? *YesNo

Please specify where

Do you have a Pacemaker fitted? *YesNo

Please Initial If you give consent *0 / 3

Consent for Use of Photographs:

I consent to the use of these photographs for professional purposes, including but not limited to educational materials, website content, and social media, provided that all identifying features (including my face and personal information) are obscured or removed.
I understand that these images will be used respectfully and will not be sold or misused.
I may withdraw my consent for future use at any time in writing.

I understand that clinical photographs may be taken before, during, or after my sessions to document progress.

I consent to the use of my de-identified photographs as described above.I do NOT consent to the use of any photographs.

Consent

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Services

Academy

Social media

Hours

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