LAMPROBE - PATIENT CONSENT FORM

To the client:

You have the right to be informed of your condition and the recommended medical, surgical or diagnostic procedure to be used. Please read this carefully, so that you may make the decision whether or not to undergo the procedure after knowing the risks or hazards involved to you. You have the right to give or withhold your consent to the procedure.

I give my permission to Source Skin Care, LLC, and its licensed practitioners to attempt to remedy the following condition(s) and symptom(s):

Skin Tags, Milia, Sebaceous Hyperplasia, Cholesterol Deposits, Cherry Angiomas, Small Broken Capillaries...etc.

1. There may need to be more treatments than anticipated to achieve the desired results.

2. I understand that smoking may increase the risk of infection, skin loss and bleeding.

3. I agree to follow and perform post-treatment care plans as instructed.

4. If I fail to perform the post-treatment care, I understand that Source Skin Care, LLC, will be relieved of responsibility for any scarring and or aesthetically undesirable effect.

5. I acknowledge the fees for the procedure have been discussed and I agree to pay the fee in full for each treatment.

6. The nature of my medical condition and the proposed health procedures together with the alternative methods of treatment have been explained to my satisfaction as well as any substantial and significant risks of serious harm.

7. I understand that sun exposure or use of tanning lamps or self tanning creams and not adhering to the post-care instructions may increase my chance of complications.

8. The practice of medicine is not an exact science. Although good results are expected, there is not a guarantee or warranty expressed or implied as to the results that may be obtained infrequently. It is necessary to perform additional treatments to improve your results.

9. I have discussed my past and present medical and treatment history with my practitioner. I acknowledge that I have been given fair opportunity to ask questions about LamProbe treatment procedure and alternatives.

10. I acknowledge that my questions have been answered to my satisfaction. I have read this consent for treatment. I fully understand and accept the potential risks and complications involved with this procedure. I freely consent to the proposed procedure.