Lemon Bottle – Comprehensive Consent and Concern Form

Client Information

Full Name *

Date of birth *

Gender *

Address

Street Address

City

Postal code

Phone Number *

Email Address *

Emergency Contact Name *

Emergency Contact Phone *

Medical History

Are you currently under medical supervision or taking medications? *

Yes

No

If yes, please provide details: *

Have you had recent cosmetic treatments (Botox, fillers, threads, peels)? *

Yes

No

If yes, please let us know: *

Treatment Goals and History

What is your primary goal with Lemon Bottle treatment? (Check all that apply): *

Let us know : *

Have you had Lemon Bottle or fat dissolving injections before? *

Yes

No

If yes, when and what was your experiene? *

Procedure Information

Lemon Bottle is a non-surgical fat-dissolving treatment using advanced natural compounds to reduce localized fat deposits.

The treatment involves injections of active ingredients (including vitamins, amino acids, and plant extracts) into targeted areas.

A course of treatments is typically needed for optimal results.

You may experience mild discomfort, swelling, bruising, or redness at the injection sites.

Risks, Side Effects, and Acknowledgements

Please read and initial the statements for Lemon Bottle procedure : *

I understand that Lemon Bottle is not a weight-loss solution but a body contouring method.

I acknowledge that common side effects include bruising, swelling, tenderness, and mild pain at injection sites.

I understand that rare side effects include allergic reaction, skin irritation, nodule formation, or infection.

I confirm I am not pregnant or breastfeeding at the time of treatment.

I understand that proper hydration, diet, and aftercare will enhance treatment results.

I will follow the pre- and post-treatment instructions provided by Idens Laser Clinic.

I consent to medical photography for documentation purposes (not shared without consent).

Client Declaration and Consent

Check all Boxes for Lemon Bottle Treatment: *

I declare that the information I have provided is accurate and complete.

I have had the opportunity to ask questions, and all have been answered to my satisfaction.

I voluntarily consent to receive Lemon Bottle fat-dissolving treatment at Idens Laser Clinic.

By signing below, I confirm that I have read and understood the information provided and consent to proceed with the treatment.

Client Signature: *

Clear

Date: *

Practitioner Name (Print): *

Practitioner Signature: *

Clear

Date: *

I agree to terms & conditions provided by the company.

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Lemon Bottle – Comprehensive Consent and Concern Form

Treatment Goals and History

Procedure Information

Risks, Side Effects, and Acknowledgements

Client Declaration and Consent

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