Self Assessment
Choose Consent Form
consent form legend english
File Number:
Consent Form - Legend
Terms and Conditions:
• During the treatment you might feel some pain, vibration, a stinging sensation and heat
• Receiving the course of treatment is my choice
• VO treatment, tiny imprint marks in the form of the electrodes or microneedles matrix configuration will usually form within 24 hours to 72 hours post treatment and last for a few days
• Must avoid scratching of the imprint marks and to apply sunscreen daily.
• Side effects including: local pain, excessive skin redness (erythema), excessive swelling (edema), damage to the natural skin texture (crust, blister, and burn), fragile skin, change of pigmentation (hyper-pigmentation or hypo-pigmentation), bruising, scarring or transient skin breakouts such as acne and pimples. Although these effects are rare and expected to be temporary, any adverse reaction should be reported immediately.
• Must avoid heat, exposure to sun and UV and to apply physical SPF sun screen several times a day
• In case of excessive swelling, redness or heat, you may apply a cold pack (Not ice) to the area
• 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
• 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
Patient Signature
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