This form is designed to give you the information you require to make an informed choice for whether or not to undergo treatment with InMode technology. If you have any questions before your treatment, please feel free to ask.
- I herby authorize Celebration Obstetrics & Gynecology and/or such assistant as may be selected to form the InMode procedure.
- I have received the information about the technology:
*InMode technology utilizes fractional radiofrequency (RF) indicated for facial/neck/chest and back of the hands, as well as small body areas.
*The InMode treatment includes ablation, thus improving the appearance of rough texture, fine lines, wrinkles, and depressed scars, such as acne scars along with superficial pigments that will be ablated. The treatment also induces skin rejuvenation by heating of the dermis which stimulates collagen generation and replenishment as well as closure of superficial fine blood capillaries.
*The treatment requires anesthesia that involves topical cream, injections, or sedation according to the treatment parameters and the physician discretion.
- I understand that taking the treatment course is my choice and that I am free to withdraw at any time, without giving any reason.
- There may be alternative procedures or methods of treatment, such as fractional lasers for ablation (CO2) and lasers, IPL or RF based systems for skin rejuvenation As of today, there are no systems in the market that can address lesions that InMode does. Details were explained to me.
- I was told about the possible side effects of the treatment including: local pain, skin redness (erythema), swelling (edema), damage to the natural skin texture (crust, blister, burn), change of skin pigmentation (hyper-hypo- pigmentation), and scarring. Although these effects are rare and may happen in dark skin that is not taken care according to instructions. Tiny scabs appear on the face for a few days as part of a normal healing, however make-up may be applied as soon as 1-3 days after the session to mask them and residual redness Any adverse reaction should be reported immediately.
- I understand that the treatment involves a few sessions (1-5 a few weeks apart (3-6 weeks), according to treatment parameters and individual response.
- I understand that I have to comply with treatment schedule, otherwise results may be compromised.
- I recognize that during the course of the procedure unforeseen conditions may necessitate different procedures than this above and I authorize the provider or assistants to perform such other procedures if they find them professionally desired.
- I understand that not everyone is a candidate for this treatment and results may vary. Therefore, there is no guarantee as to the results that may be obtained.
- If my provider feels that my health is compromised at any time of the treatment, he/she has the right to cease the treatment for my protection.
The procedures to be used to treat my conditions have been explained to me.