miraDry Consent

We are 100% committed to the health and well-being for everyone. We are doing everything we can to keep potential exposure out of our office.

As part of the local and state guidelines you must answer no to all the following questions each time you enter Pua Manu Medspa.

• Not present a fever over 100 F/ 37 C.
• Not presenting cold, cough, difficulty breathing muscle pain, headache,
  loss of taste/smell or pink eye in past 14 days.
• Not in contact with anyone with these symptoms in the past 14 days.
• Not been off island and returned without being quarantined for 14 days.
• Not in contact with anyone diagnosed with COVID-19, sick and quarantined, in the past 14 days.

All information above is true. I may be asked again when I arrive for my appointment. 
ALL PATIENTS AND STAFF ARE REQUIRED TO: 

• Please follow our local and state regulations and guidelines, including those related to occupancy levels, social distancing and other measures intended to reduce the spread of viruses.
• Stay home if you are sick or are exhibiting symptoms of illness such as a fever or persistent cough.
• Face mask are required to enter the Spa.
• Refrain from shaking hands or other touching rituals.
• Wash hands for 60 seconds with soap and warm water prior to treatment or use hand sanitizer.
• Refrain from eating or drinking while in the Spa, face mask should not be removed. 

I agree to comply to the rules listed above.

 

I also understand that the novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. I further understand that COVID-19 is extremely contagious and is believed to spread by person-to-person contact, and as a result, federal and state health agencies recommend social distancing. I understand that Pua Manu Medspa has put in place reasonable safety measures to help reduce the spread of COVID-19.

I understand that COVID-19 may cause additional risks, some of which may not be known at this time.

I understand that I am consenting to an elective treatment/procedure that is not urgent or emergent. I understand that it may put me at increased risk for becoming infected with COVID-19, due to potential community exposure.

PATIENT’S ACCEPTANCE OF RISKS

By signing this consent form I accept the risks described above and give my permission to proceed with the treatment/procedure.

I have read this consent or someone has read it to me and want to proceed.

The miraDry procedure is a highly controlled delivery of energy designed to safely and effectively reduce sweat and odor in the underarm area. Patients may also experience a reduction in underarm hair. Typically patients may see a reduction in underarm sweat in as little as one treatment. In controlled clinical trials between 70% and 90% of subjects saw a significant reduction in their underarm sweat and virtually all the subjects achieved some reduction. Patients continued to show a dramatic reduction of sweat when tracked for 12 months after the procedure. Like any other medical procedure, results can vary from patient-to-patient, so be advised that large reduction may not occur in every single case. 

The miraDry System is contraindicated in people:

• WITH HEART PACEMAKERS AND OTHER ELECTRONIC DEVICE IMPLANTS
• WHO NEED SUPPLEMENTAL OXYGEN
• WITH KNOWN RESISTANCE TO OR HISTORY OF INTOLERANCE OF LOCAL ANESTHESIA INCLUDING LIDOCAINE AND EPINEPHRINE 

Please inform the Doctor or Nurse if you are:

• PREGNANT
• HAVE ANY UNDERLYING SKIN CONDITIONS
• HAVE HAD PREVIOUS AXILLARY SURGERY

 

 

Risk and discomforts:

The following represent the more common side effects observed within or near the treatment area that can last between a few days and a few weeks (unless otherwise noted):

• Swelling in the treated area
• Temporary altered sensation or tingling in the treated skin and/or upper arm (can last for several months)
• Discomfort, tenderness or pain in the under arm when touched (treatable with a non-prescription medication such as ibuprofen)
• Redness from the device suction
• Bruising from the treated skin 
• Bumps under the treated skin (can last for several months)
• Partial Underarm hair loss (may be long lasting)

 

Less common reports of undersired effects include the following:

• Swelling in the adjacent arm or torso lasting sevarl weeks
• Hyperpigmentation (darkening of skin) in the treatment area
• Soreness in the shoulders or arms due to procedure positioning
• Numbness or tingling in the arm due to anesthesia, lasting less than 24hours
• Tight banding in the underarm (gradually resolves)

 

There have been rare reports of the following:

• Altered swelling elsewhere on the body
• Small blisters/ulcerations or rashes in the treatment area
• Temporary altered sensation or tingling in the forearm or fingers (can last for several months)
• Weakness in the arm or fingers that gradually goes away (can last for several months)
• Pain in the underarm requiring prescription medications
• Infection/chronic infection/abscess
• Thermal injury to the axilla nerve in thinner patient
• Burns

I understand that miraDry is an elective procedure, that insurance does not cover this procedure and that I am solely responsible for payment. Fee structure and payment have been fully explained to me. I have been quoted a total of 

+ tax. I will be asked to pay this amount in full prior to the procedure. Please initial.

I understand that necessary photos may be taken before, during and after the course of my treatments for medical purposes and to evaluate treatment effectiveness. I understand that my photos will be kept confidential in my electronic patient record.

I have read and understand all of the information presented to me before signing this consent form. I have been given the opportuninity to have all of my questions answered to my satisfaction. I understand the procedure and accept the risks. I authorize Dr. Chen or the licensed provider to perform miraDry Treatment on me. I agree to the terms of this agreement.