Consent Form - Radio Frequency Services

Consent Form - Radio Frequency Services

Native Beauty Medical Esthetics LLC
Name

First NameLast Name
Radio frequency skin tightening procedure by Viora, is designed to naturally stimulate the growth of collagen and elastin in your skin by producing electromagnetic fields, causing the oscillation of molecules within the tissue, which results in the generation of heat. This is an example of how much radiation is used in this procedure:
Below is a list of contraindications that could cause adverse effects, unless your doctor has approved you for this treatment, skin tightening radio frequency will not be performed on the following conditions:
PregnancyAny skin disease in the treatment areaHistory or current tattoo or permanent makeup in the treatment areaHip replacement or other metallic deviceCardiac pacemaker, defibrillator, implanted electronic/electrical deviceBlood coagulopathy or excessive bleeding or bruising, use of blood thinning medicationsHistory of deep vein thrombosisActive or recent malignancy (cancer)Any endocrine disorder, such as diabetes, hormonal disorders, thyroid disordersHepatitis or liver diseaseImmune system disorders and use of drugs that influence the immune systemHeat induced diseases (herpes in the treatment area)Any active skin disease in the treatment area (such as herpes, eczema, rash)Extra dry or sensitive skinInjections - Please wait 2 weeks after Botox or fillersRetin A, stop 5-7 days before treatmentPeel in the last 2 weeksBreastfeeding in the last 3 monthsChildbirth in the last 6 months3-6 months recent surgery in treatment area, allow sutures to dissolve, area to heal. (Liposuction, subcision)
These are common possible side effects:
- side effects may appear either at the time of appointment or shortly after
- some dark-skinned patients may have a delayed response one-to-two days after treatment and should be evaluated post-test spot accordingly
- The side effects may include:
1. Discomfort
2. excessive skin redness
3. damage to natural skin texture (bruise, blister, burn)
4. change of pigmentation (hyper- and hypo-pigmentation
- Proper use of the Viora’s treatment protocol and operative instructions will prevent or minimize adverse effects.
- If you suffer from any side effects more severe than listed above you should seek physician care.
- although these side effects are rare and expected to pass, any adverse reaction should be immediately reported to your skin care professional.
- The decision to have skin tightening treatment is extremely personal and you’ll have to decide if the benefits will achieve your goals and if the risks and potential complications are acceptable.
I fully understand these risks and possible adverse effects Signature
Setting my goals and expectations, realistically.
- Treatment provides gradual improvement of skin texture/laxity without downtime or high risk factors
- superficial acne scarring and enlarged pores may show some improvement by building new collagen in the dermal area
- Weight fluctuations may influence the results
- patients with poor diet, constant sun exposure, or smoking will need more treatments, more frequent maintenance meetings, and may have only a moderate response.
- Stretch marks and scars-will never disappear! We can expect improvement in their color, latitude and longitude. While stretch marks are mutch more difficult to improve (additional technologies are usually used in combination, such as microneedling)
- Wrinkles-will never disappear, but we can expect their thinning and flattening
- Response to treatment and number of sessions required will vary among patients, depending on clinical and physiological condition at the start of the treatment regimen.
YesNo
YesNo
My provider has thoroughly gone through the risks and contraindications for the skin tightening procedure. I understand and accept to have this procedure performed, not holding the skin care professional liable for these risks if they do occur.
Signature

Clear
Date

MonthDayYear
Date
Should be Empty: