Zemits Machine Treatment – 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 receiving medical treatment or taking medications? *

Yes

No

If yes, please specify:

Do you have any known allergies or sensitivities? *

Yes

No

Have you had recent cosmetic procedures (fillers, Botox, peels, laser)? *

Yes

No

If yes, please describe and provide dates:

Treatment Goals and Preferences

Have you used Zemits or other aesthetic machines before? *

Yes

No

If yes, what was your experience?

Treatment Information

Zemits devices may use technologies such as radiofrequency, vacuum therapy, ultrasound, microcurrent, or LED to enhance skin tone, reduce fat, and improve circulation.

Each treatment type is designed to be non-invasive with little to no downtime.

You may experience warming, suction, or tingling sensations during the procedure.

A series of treatments is typically recommended for best results.

Risks, Side Effects, and Acknowledgements

Please read and initial each statement: *

I understand that Zemits treatments are non-invasive and intended for aesthetic improvement.

I acknowledge potential side effects such as redness, swelling, tenderness, or temporary irritation.

I understand that results vary by individual and that multiple sessions may be necessary.

I confirm that I have disclosed all relevant health history, medications, and treatments.

I will follow pre- and post-treatment care instructions provided by the clinic.

I consent to clinical photographs for documentation (not for public use without permission).

Client Declaration and Consent

Check all the boxes :

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

I understand the purpose, benefits, and risks of Zemits treatments and have had my questions answered.

I voluntarily consent to receive Zemits machine treatments 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: *

Deposit & Risk Acknowledgment Policy

Non-Refundable Deposit

I understand and agree that any deposit made for medical consultations, procedures, or treatments is non-refundable under all circumstances. This applies regardless of cancellation, rescheduling, or change of decision on my part.

Assumption of Risk

I acknowledge that all medical treatments, procedures, or interventions carry inherent risks. I have been informed of the potential benefits, risks, and alternatives related to my care, and I have had the opportunity to ask questions. I voluntarily assume full responsibility for any and all risks, outcomes, or complications that may arise from the medical care I receive. I release the provider and facility from liability for outcomes that are not guaranteed and may vary from patient to patient

Confirmation of Understanding

By signing below, I confirm that:

- I have read and fully understood this policy

- I understand the deposit is non-refundable.

- I accept and assume all risks related to my treatment.

- I sign this document voluntarily and without coercion.

Patient Name

Patient Signature:

Clear

Date: *

I agree to terms & conditions provided by the company.

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