SculpSure

We are 100% committed to the health and well-being for everyone. We are doing everything we can to keep potential exposure out of our office.

As part of the local and state guidelines you must answer no to all the following questions each time you enter Pua Manu Medspa.

Not present a fever over 100 F/ 37 C.
Not presenting cold, cough, difficulty breathing muscle pain, headache,
loss of taste/smell or pink eye in past 14 days.
Not in contact with anyone with these symptoms in the past 14 days.
Not currently under quarantine order or directive.
Not in contact with anyone diagnosed with COVID-19, sick and quarantined, in the past 14 days.

All information above is true. I may be asked again when I arrive for my appointment.
ALL PATIENTS AND STAFF ARE REQUIRED TO:

Please follow our local and state regulations and guidelines, including those related to occupancy levels, social distancing and other measures intended to reduce the spread of viruses.
Stay home if you are sick or are exhibiting symptoms of illness such as a fever or persistent cough.
Face mask are required to enter the Spa.
Refrain from shaking hands or other touching rituals.
Wash hands for 60 seconds with soap and warm water prior to treatment or use hand sanitizer.
Refrain from eating or drinking while in the Spa, face mask should not be removed.

I agree to comply to the rules listed above.

I also understand that the novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. I further understand that COVID-19 is extremely contagious and is believed to spread by person-to-person contact, and as a result, federal and state health agencies recommend social distancing. I understand that Pua Manu Medspa has put in place reasonable safety measures to help reduce the spread of COVID-19.

I understand that COVID-19 may cause additional risks, some of which may not be known at this time.

I understand that I am consenting to an elective treatment/procedure that is not urgent or emergent. I understand that it may put me at increased risk for becoming infected with COVID-19, due to potential community exposure.

PATIENT’S ACCEPTANCE OF RISKS

By signing this consent form I accept the risks described above and give my permission to proceed with the treatment/procedure.

I have read this consent or someone has read it to me and want to proceed.

Signature

Name

Last NameFirst Name

The SculpSure™ delivers laser energy to heat the deep layer of fat. The heat that is created damages the fat cells. The damaged fat cells are then eliminated by the body through your lymphatic system.

During the laser delivery the applicators cool the skin throughout the entire treatment. The cooling protects your skin while the energy heats your fat layer. When the treatment begins, it will feel warm, and over time the heat sensation will increase to short periods of intense deep heat. You may also experience some cramping, tingling, prickling or squeezing sensations deep in the fat layer. These sensations are normal and expected. These sensations indicate that the laser is effectively targeting and damaging the fat layer.

The SculpSure is eye safe. There is no need to wear protective eyewear.
Your skin may be slightly pink to red immediately after treatment. This may last for a few hours.
There are no lifestyle restrictions following your SculpSure treatment. It is recommended to increase your water intake after treatment.
You may use ice packs or Tylenol according to package instructions to help ease tenderness.

Following the SculpSure treatment you may experience some swelling, tenderness, bruising firmness or hardness at the treatment site. This usually resolves within 2 weeks but may last longer. Other less common side effects which can occur are itching, skin contour irregularities, dimpling, hyperpigmentation/hypopigmentation, asymmetry, necrosis, changes in skin laxity, numbness, blister or burn.

Initial Here

I have been thoroughly and completely advised regarding the end point of the procedure. I understand that the practice of medicine is not an exact science and no results have been guaranteed. I acknowledge that the results may not meet my expectations. I certify that no guarantees have been made by anyone regarding the procedure(s) that I have requested and authorized. There is no guarantee that the expected or anticipated results will be achieved.

Initial Here

I confirm that I have not had sun exposure within the last 7 days.

Initial Here

I consent to photographs and digital images being taken and used to evaluate treatment effectiveness, for medical education, training, professional publications or sales purposes. No photographs or digital images revealing my identity will be used without my written consent. If my identity is not revealed, these photographs and digital images may be used, shared, and displayed publicly for such stated purposes without my permission.

Initial Here

Before and after treatment instructions have been discussed with me. The procedure, potential benefits and risks, and alternative treatment options have been explained to my satisfaction.

Initial Here

Contraindications

An active tan, or the need to be exposed to artificial tanning devices or excessive sunlight a week (7 days) before or after treatment.
Prior treatment with parental gold therapy (gold sodium thiomalate)
Currently pregnant or pregnant within the last three months, currently breastfeeding or planning a pregnancy during the course of the treatment
History of skin photosensitivity disorders, or is taking photo-sensitizing medication
Previously had liposuction or lipo-sculpture or any type of procedure in the treatment area
Open lesions and wounds. Treatment is to be applied to intact, healthy skin, with no evidence of compromised wound healing
Unrepaired abdominal hernia
Large transverse or vertical abdominal scars
Has a history or evidence of squamous cell carcinoma or melanoma
Has a neuropathic disorder, impaired skin sensation, or diabetic neuropathy
History of immunosuppression / immune deficiency disorders, including HIV infection or AIDS, or use of immunosuppressive medications
Received or is anticipated to receive antiplatelets, anticoagulants, thrombolytics, or anti-inflammatories within two weeks prior to treatment
Has a coagulation disorder or is currently using anti-coagulation medication, including but not limited to the heavy use of aspirin, i.e., greater than 81 mg per day
Has a history of Keloid scar formation

Post-treatment Instructions

SculpSure™ Post-treatment instructions:

May experience mild pinkness or redness, tenderness, swelling, pain, itching, and skin firmness.
Tenderness may last up to two weeks and in some clients a bit longer.
Use a cold compress and/or acetaminophen to help relieve tenderness.
Gently massage the area twice a day for 5-10 minutes.
May resume normal daily activity including exercise immediately post treatment.
Encourage proper hydration and light physical activity to help mobilize fat via the lymphatic system.
Contact your physician if you have any concerns about your treatment areas such as increasing tenderness or swelling several days after your treatment, or if you develop blisters, hardened areas or nodules.

I understand that necessary photos will be taken before, during and after the course of my treatments for medical purposes and to evaluate treatment effectiveness. I understand that my photos will be kept confidential in my electronic patient record.

Initial Here

I agree to return to take photos 12 weeks after the procedure and I will not hold Pua Manu MedSpa liable for the outcome if I do not comply with this requirement.

Initial Here

I understand that results vary, and two treatments minimum are recommended per area for the average person under 30 BMI. I understand that I may or may not see results with one treatment.

Initial Here

I understand that this works best in conjunction with proper nutrition, hydration, and exercise. Pua Manu MedSpa is not responsible for results if I have an overall unhealthy diet and no physical activity. This can be evidenced by weight gain and/or an increase in body measurements.

Initial Here

I have communicated my expectations of the results with the service provider.

Initial Here

Payment Policy: My signature below certifies that I hereby seek the services of SculpSure for body contouring. I understand that cosmetic treatments, including SculpSure are voluntary procedures and are not covered by Insurance Plans. I understand that payment is due before services are rendered. I also understand and agree that if I pay for a package of services using a credit card, check or finance company, and the payment is not honored or is subject to a chargeback at any time for any reason that I am still fully responsible for payment of the treatments I receive. I agree to pay for such services at the undiscounted or regular pricing. I further acknowledge that I am personally responsible for all fees and charges incurred in connection with my purchase. I also completely understand that there is absolutely NO REFUNDING of any patient fees, payments, charges, gift certificates, or pre-paid packages.

I assume all risks as my own and agree to hold harmless, Pua Manu MedSpa. their providers, estheticians, and any other staff member, affiliate, or independent contractor. I hereby release them from any liability, both seen and unforeseen, now and forever.

I have read and understand all information presented to me before signing this consent form. I have been given an opportunity to have all my questions answered to my satisfaction. I understand the procedure and accept the risks. I agree to the terms of this agreement.

Patient Signature

Print Name

Date

Providers Signature

SculpSure Consent Form