Exilis Elite Patient Consent
1. Purpose and Background
The Exilis Elite treatment is a non-surgical procedure designed to deliver radiofrequency (RF) energy to targeted areas to reduce fat, improve skin laxity, and promote collagen production. Exilis Elite is commonly used for body contouring, skin tightening, and rejuvenation.
2. Procedure
During the treatment, a specialized device will deliver RF energy to the skin, producing a warming sensation. This energy helps target fat cells and stimulate collagen. The procedure typically takes 15-30 minutes per session, with minimal downtime.
3. Expected Benefits
•Improved skin firmness and elasticity.
•Reduction in the appearance of fine lines and wrinkles.
•Fat reduction in targeted areas.
4. Contraindications
I have been questioned and deny any of the following contraindications for treatment:
•Bacterial or viral infection, acute inflammations
•Impaired immune system
•Isotretinoin in the past 12 months of the treatment area
•Scleroderma
•Radiation therapy
•Burns in the treatment area
•Poor healing in the treatment area
•Metal implants
• Implantable pacemaker or automatic defibrillator / cardioverter
• Ablative / non-ablative cosmetic intervention (deep peeling) in the past 3 months of proposed treatment area
• Cancer
• Active collagen diseases
• Cardiovascular diseases (such as vascular diseases, peripheral arterial disease, thrombophlebitis and thrombosis)
• Pregnancy or IVF procedure
• Acute neuralgia and neuropathy
• Blood disorders, risk of bleeding, bleeding tissues, peptic ulcers
• Eczema
• Rosacea
• Febrile conditions
• Kidney or liver failure
• Pronounced edemas, ascites, exudates
• Sensitivity disorders in the treatment area
• Tuberculosis
• Varicose veins
5. Risks and Side Effects
I understand that, as with any cosmetic treatment, there are risks and potential side effects, including:
•Redness, swelling, or mild discomfort in the treated area.
•Temporary changes in skin texture, firmness, or sensation.
•Burns or blisters due to heat from the RF energy.
6. Treatment Expectations
I understand that results vary between individuals, and multiple treatments may be necessary to achieve optimal results. There is no guarantee of the outcome, and follow-up sessions may be required.
7. Alternatives
I acknowledge that alternative treatments are available, including but not limited to surgical procedures, other non-invasive devices, or doing nothing. I have been informed of these options and their associated risks and benefits.
8. Confidentiality
My treatment and personal information will remain confidential in accordance with HIPAA regulations. Only authorized personnel involved in my treatment will have access to my records.
9. Consent and Release
I acknowledge that I have discussed the Exilis Elite procedure, including benefits, risks, and alternatives, with my provider. I agree to follow any pre- and post-treatment instructions provided by my practitioner. I also understand that this is a voluntary procedure and that I am free to withdraw my consent at any time.