triLift Consent Form

triLift Consent Form
Name

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Referred By:
I hereby certify that I am above 18 yrs old and authorize Beauty By Kitten, LLC to perform Lift Mode TriPollar® RF Energy with DMSt™ muscle conditioning / triFX™ RF-assisted micro needling / triLift™ synergistic procedures on me, in an effort to improve my facial skin / muscle tone / mild-to-moderate facial wrinkles and rhytides / Other
Please initial to acknowledge your understanding of our consent form:
I understand that there is a rare possibility of adverse effects including discomfort, excessive skin redness, excessive swelling, damage to the natural skin texture (in the form of blisters or burns), fragile skin, change of pigmentation, bruising, scarring or transient skin breakouts such as acne or milia. In the event of any such adverse reaction, although expected to be transient, I understand that I need to report it to my healthcare provider above and I am aware that careful adherence to all advised instructions will help reduce such a possibility.
Please initial to acknowledge your understanding of our consent form:
I understand the below list of short-term effects and agree to follow matching guidelines:
- Discrete micro scabs post triFX™ micro needling - will usually form within 24 hours to 3 days post treatment and last for a few days during which natural and gradual flaking occurs. During this phase, it is important not to manipulate or scratch the skin which may otherwise lead to scarring.
- Mild itchiness and/or sensation of dry skin post triFX™ micro needling – may be relieved with cold air or thermal spring water sprays within the first 24 hours. I may apply soothing creams or serums as of 1 day post treatment but not earlier.
- Slight warmth and/or cramp-like feeling post Lift Mode – may occur in some localized areas. Dissipates spontaneously and may be relieved with cold (but not iced) packs.
Please initial to acknowledge your understanding of our consent form:
I understand the below list of short-term effects and agree to follow matching guidelines:
- Discrete micro scabs post triFX™ micro needling - will usually form within 24 hours to 3 days post treatment and last for a few days during which natural and gradual flaking occurs. During this phase, it is important not to manipulate or scratch the skin which may otherwise lead to scarring.
- Mild itchiness and/or sensation of dry skin post triFX™ micro needling – may be relieved with cold air or thermal spring water sprays within the first 24 hours. I may apply soothing creams or serums as of 1 day post treatment but not earlier.
- Slight warmth and/or cramp-like feeling post Lift Mode – may occur in some localized areas. Dissipates spontaneously and may be relieved with cold (but not iced) packs.
Please initial to acknowledge your understanding of our consent form:
The procedure as well as potential benefits and risks have been thoroughly explained to me and I have had all my related questions answered. Pre- and post-care instructions have been discussed and are completely clear to me.
Please initial to acknowledge your understanding of our consent form:
I understand that results may vary with each individual and acknowledge that it is impossible to predict how I will respond to the treatment and how many sessions will be required.
Please initial to acknowledge your understanding of our consent form:
I consent to photographs being taken for the purpose of documenting my progress and response to the treatment and be kept in my medical record. I understand these may be used for advertising or social media posts and education purposes.
Please initial to acknowledge your understanding of our consent form:
Please sign to acknowledge your acceptance of the consent to treatment:
Date Signed:

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2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: