consent form cellfina

File Number:

Consent Form - Cellfina

Alternative Treatments

The Cellfina® treatment using the Cellfina® system is one option for treating cellulite. The Cellfina® treatment is a cosmetic treatment and as such is designed to treat the appearance of cellulite on the buttocks and thigh. There may be other alternative cosmetic treatments for tackling cellulite which you can discuss with your practitioner

Terms and Conditions:

All surgical treatments and operations carry at least a small risk and side effects, such as pain, bleeding and infection.

1. Potential side effects include:

2. Potential risks associated with Cellfina® treatment:

• Blanching and discoloring (generalized whiteness)

• Abscess (localised collection of pus)

• Bruising

• Development and/or removal of fluid

• Fluid accumulation (i.e. swelling, oedema)

• Anetoderma (area of skin looseness or laxity)

• Hematoma (localised collection of blood)

• Extravasation (migration of fluid)

• Haemosiderosis (appearance of bruising that lasts longer than

• Bleeding

normal due to iron deposits under the skin

• Fibrosis (development of excess fibrous tissue)

• Hyperpigmentation (darkening of the skin) / Hypopigmentation

• nfection

• (lightening of the skin)

• Nausea/vomiting

• Induration (firmness or hardness under the skin)

• Numbness/tingling

• Inflammation/generalized redness

• Scarring or keloid (raised, pinking scar like formation)

• Bleeding from needle and blade punctures

• Changes in sensitivity to the skin (i.e. numbness, tingling)

• Skin necrosis (death of skin cells)

• Redness

• Toxic, allergic, or other reaction from the device or injected anesthetic

• Erythema (patches of redness)

• understanding of all this information

• Rash in the treatment or surrounding areas

• Red spots (from needle/blade punctures)

• Skin surface profile change or irregularity

• Soreness, pain and/or vacuum acquisition marks (marks
on the skin caused by the device’s vacuum pressure
against the skin)

• I confirm that the risks, benefits and alternatives of this procedure have been discussed with me

• Client experiences may vary.

• Any contraindications will void this treatment

• This treatment cannot be transferred to another person

• The result is staged; there are no absolute guarantees as to the outcome that can be expected.

• Choice of correct candidate for this treatment is done by the doctor

• I confirm that I have chosen this procedure to be done by the above physician willingly and voluntarily.

• If any unforeseen condition arises during this procedure which requires transportation to a hospital, additional procedures, operation or medication including anesthesia and blood transfusions, I further request and authorize my physician to do whatever he deems advisable on my behalf and I confirm that I have agreed to pay for these services.

• I am aware that the practice of medicine and surgery is not an exact science, and I acknowledge that no guarantees have been made to me concerning the results of this procedure.

• No refunds will be provided for any services

No other party other than I am held responsible for the services or treatments of any complications.

I am a competent consenting adult of at least 18 years of age (or my parent or legal guardian is giving consent on my behalf), and further:

• Pre and post treatment instructions have been explained to me

• I have had sufficient time to consider the Cellfina® treatment and had the opportunity to ask questions, and all of my questions have been answered to my satisfaction and understanding

• Must notify the clinician if my medical history changes prior to subsequent treatments

• I consent to clinical photographs being taken of my treated areas for my personal health record only

My signature below constitutes my acknowledgment and understanding of all this information

Patient Name

Patient Signature

Date & Time

Parent or Guardian (if patient is minor)

Witness