consent form endymed english

• Multiple treatments are recommended for optimal results and that there is no guarantee that the wrinkles/rhytides will be completely removed or reduced in appearance.

• There is a possibility of adverse effects such as heating sensation, prolonged erythema, and dry skin. Burns and blisters may occur in rare situations. These possible adverse effects have all been fully explained to me.

• There are other options for wrinkle and rhytides treatment that are available and each of these other options have fully been explained to me.

• I DO NOT have a pacemaker, or other implanted metal device nor do I have arrhythmia or other known heart disease/ailment.

• I DO NOT have any implanted metal plates around the treatment area.

• I Have NOT taken any medication that affects the characteristics of the skin such as Accutane or Isotretinoin.

• I AM NOT currently pregnant or nursing.

• I DO NOT HAVE any piercings or permanent make up in the treatment area.

• I DO NOT have an autoimmune disorder or untreated diabetes

• I AM NOT being treated for a blood clotting disorder nor do I take medication associated with a clotting disorder.

• 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

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

• 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