Define Consent

Name

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.

Medical History: Please click all that apply

Pacemaker/ DefibrillatorMetal ImplantsCurrent or History of Skin Cancer/ Other Cancer/ Pre-Malignant Moles/ Suspicious LesionsSevere Concurrent Medical Conditions (ex. Cardiac Disorders)Active Skin Infection (ex. psoriasis, eczema)Skin Disorders / Conditions (ex. keloids, adnormal wound healing, vitilgo)History of Bleeding DisordersPregnancy and NursingImpaired Immune SystemDiseases Stimulated by Light (ex. Lupus, Porphyia, Epilepsy)Intra-Dermal or Superficial Sub-Dermal Injections/ Fillers/ GraftsDiseases Stimulated by HeatEndocrine Disorders (ex.Diabetes, PCOS)Facial Laser Resurfacing/ Deep Chemical Peeling (last 3 months)Needle Epilation, Waxing, Tweezing (last 6 weeks)Tattoo or Permanent MakeupCurrent or Past History of Gold TherapyTanned SkinSaphenous Insufficiency/ Severe Varicosity

If yes to any of the above Medical History, Elaborate below

Surgical Procedures, Year of Procedure

Current Medications with Dose

List any Allergies with reactions

I understand that the device being used for skin appearance improvement, of which I am consenting
to be a patient receiving Define treatment.
I understand that clinical results may vary depending on individual factors, including but not limited
to medical history, skin type, patient compliance with pre- and post-treatment instructions, and
individual response to treatment.

I understand that there is a possibility of short-term effects such as reddening, mild burning,
temporary bruising and temporary discoloration of the skin, as well as the possibility of rare side
effects such as scarring and permanent discoloration. These effects have been fully explained to me.

I understand that treatment with this system involves a series of treatments and the fee structure
has been fully explained to me.

I certify that I have been fully informed of the nature and purpose of the procedure, expected
outcomes and possible complications, and I understand that no guarantee can be given as to the final
result obtained. I am fully aware that my condition is of cosmetic concern and that the decision to
proceed is based solely on my expressed desire to do so. I confirm that I have informed the staff
regarding any current or past medical condition, disease or medication taken.

I consent to the taking of photographs and authorize their anonymous use for the purposes of medical
audit, education and promotion.

I certify that I have been given the opportunity to ask questions and that I have read and fully
understand the contents of this consent form.

Signature

Date