Aesthetics Consent Form

Patient Name*

First NameLast Name

Patient DOB*

Date

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Cell Phone Number

Please enter a valid phone number.

Home Phone Number

Please enter a valid phone number.

Email

example@example.com

Emergency Contact Name

First NameLast Name

Emergency Contact Phone Number

Pregnancy or nursing*

YesNo

Under 18 Years of age*

YesNo

Pacemaker or internal defibrillator or any electronic implant such as a glucose monitor*

YesNo

Permanent implant in the expected treated area such as metal plates and screws, silicone implants, or an injected chemical substance*

YesNo

Current or history of cancer, especially skin cancer, or pre-malignant moles*

YesNo

Impaired immune system due to immunosuppressive diseases such as AIDS and HIV, or use of immunosuppressive medications*

YesNo

Severe concurrent conditions such as cardiac disorders, epilepsy, uncontrolled hypertension, and liver or kidney diseases*

YesNo

A history of diseases stimulated by heat, such as recurrent Herpes Simplex, in the treatment area*

YesNo

Any active condition in the treatment area, such as sores, psoriasis, eczema and rash as well as excessively/fresh tanned skin*

YesNo

History of skin disorders such as keloid scarring, abnormal wound healing, as well as very dry and fragile skin*

YesNo

Any medical condition that might impair skin healing*

YesNo

Poorly controlled endocrine disorders, such as diabetes or thyroid dysfunction*

YesNo

Any surgical, invasive, ablative procedure in the treatment area in the last 3 month or before complete healing*

YesNo

Superficial injection of biological fillers in the last 6 months, or Botox in the last 2 weeks*

YesNo

Use of Isotretinoin (Accutane) within 6 months prior to treatment*

YesNo

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 hereby authorize Celebration Obstetrics & Gynecology and/or such assistant as may be selected to form the InMode procedure.

I have received the following 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 the dermis which stimulates collagen generation and replenishment as well as the 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's 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-hypopigmentation), and scarring. Although these effects are rare and may happen in dark skin that is not taken care of according to instructions. Tiny scabs appear on the face for a few days as part of 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 the treatment schedule, otherwise, results may be compromised.
I recognize that during the course of the procedure, unforeseen conditions may necessitate different procedures than those 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 during 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.

Patient Initials*

Provider/Assistant Initials

1. I have sufficient opportunity to discuss my condition and treatment I believe I have adequate knowledge upon which to base an informed consent.

2. Any questions I may have asked have been answered to my satisfaction.

3. I authorize before, during and after the procedure(s) the taking of photographs to be part of my patient profile that may be used for scientific or marketing purposes without disclosing my identity (eyes will be masked in the photographs).

Patient Signature*

Patient Name *

First NameLast Name

Date*

Date

Provider/Assistant Signature

Provider/Assistant Name

First NameLast Name

Date

Aesthetics Consent Form

Patient Information

Medical History

Informed Consent for InMode Treatments