The Art Of Cosmetic Aesthetics

Please inform medical professional/technician prior to treatment if you have any of the following conditions that may make you unsuitable for LUMECCA IPL treatments.

Under 18 years of age (unless there is parents' consent)

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

Current or history of cancer, especially skin cancer, or pre-malignant moles Impaired immune system due to immunosuppressive diseases such as AIDS and HIV, or use of immunosuppressive medications

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

A history of diseases stimulated by heat, such as recurrent Herpes Simplex in the treatment area (prophylactic treatment may be given)

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

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

Tattoos, permanent make-up, pigmented lesions (to be kept)

Any medical condition that might impair skin healing

Poorly controlled endocrine disorders, such as diabetes or thyroid dysfunction Any surgical, invasive, ablative procedure in the treatment area in the last 3 months or before complete healing

Use of Isotretinoin (Accutane) within 6 months prior to treatment This form is designed to give you the information you require to make an informed choice of whether to undergo treatment with LUMECCA technology. If you have any questions before your treatment, please feel free to ask. I hereby authorize Bel Viso Medical Aesthetics, LLC and/or such assistants as may be selected to perform the LUMECCA procedure. The medical professional obtained my medical history and found me eligible for treatment I have received the following information about the technology: o LUMECCA is a non-invasive IPL (Intense Pulse Light) technology that utilizes the technology for Skin Rejuvenation, Pigmented and Vascular lesions improvement. o Pigmented lesions will become darker for a period of 1-2 weeks before starting to lighten. Local inflammation around the lesions, manifested as some redness and swelling may accompany the response, as part of the healing process. oBlood capillaries will clot and appear darker for 1-2 weeks before disintegration. Some redness and swelling may accompany the response, as part of the healing process. o Some skin tightening may occur immediately, which may decline for 1-2 months, but will improve then, as new collagen fibers are produced. oAll 3 lesions: brown, red and loose skin may improve simultaneously. o No complete clearance is guaranteed o Treatment requires a number of sessions o Exact number of sessions is individual o There may be some discomfort and transient redness and/or swelling associated with treatment

o There is a small risk of adverse reactions

I understand that taking the treatment course is my choice and that I am free to withdraw at any time, without giving any reason Iunderstand that I am responsible for treatment payments at the time of treatment. Iwas 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 pigmentation (hyper or hypopigmentation), and scarring. Although these effects are rare and expected to be temporary, any adverse reaction should be reported immediately I understand that I must comply with treatment schedule, otherwise results may be compromised. I recognize that during the course of the treatment, unforeseen conditions may necessitate different procedures than this above and I authorize the medical

professional 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. The procedures to be used to treat my conditions have been explained to me. 1. I have had 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 4.I understand that all this is an elective treatment and that all sales are non- refundable or exchangeable and this elective treatment is a final sale.