By signing below I confirm that I do not have a cardiac implant (including defibrillator/pacemaker) nor have I been diagnosed with Myocardial Arrhythmia or Epilepsy. Furthermore, I agree to keep Peachy Laser Lounge's clinical team informed should I have a defibrillator/pacemaker or any cardiac device implanted or be diagnosed with Myocardial Arrhythmia or Epilepsy during the course of treatment. I understand that this procedure should not be performed on patients who have a cardiac implant (including defibrillator/pacemaker) or have been diagnosed with Myocardial Arrhythmia or Epilepsy.
For women of childbearing age: By signing below I confirm that I am not pregnant and do not intend to become pregnant anytime during the course of treatment. Furthermore, I agree to keep Peachy Laser Lounge's clinical team informed should I become pregnant during the course of treatment. I understand that this procedure should not be performed on patients who are pregnant.
ACKNOWLEDGMENT
BY MY SIGNATURE BELOW, I ACKNOWLEDGE THAT I HAVE READ AND FULLY UNDERSTAND THE CONTENTS OF THIS INFORMED CONSENT FOR THE TRUFLEX PROCEDURE, AND THAT I HAVE HAD ALL MY QUESTIONS ANSWERED TO MY SATISFACTION BY MY HEALTHCARE TEAM.