FaceTite/ BodyTite Informed Consent

Name

First NameLast Name

DOB

Date

I request and authorize Jennifer McCabe Lentz, MD, or designated person, to perform a procedure on me known as: Skin Tightening and Body Sculpting utilizing temperature-controlled Radio Frequency technology. This procedure is being used to treat my condition/medical diagnosis of: Laxity and/or Adiposity

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Area(s) to be treated

The areas for treatment have been reviewed with me and I am in agreement. I have been thoroughly and completely advised regarding the objectives of the procedure. I understand that the practice of medicine and surgery is not an exact science and although these procedures are effective in most cases,no results have been guaranteed. I acknowledge that imperfections might ensue and that the operative result may not live up to my expectations. I understand that skin tightening may not be fully apparent for 6-12 months after this procedure, that tissue tightening varies from individual to individual and results are age-dependent.

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The treatment will involve applying heat to the adipose (fat) tissue and dermis using radiofrequency for therapeutic purposes and may be combined with Lipoaspiration.

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I consent to the administration of local and tumescent anesthesia. I understand that all forms of anesthesia involve risks and the possibility of complications, injury or death.

Discomfort may be experienced during and/or after the treatment.

Some bruising and/or swelling may occur following the procedure. However, it should resolve in days, weeks, or months.

Temporary redness (erythema) and swelling of the treated area can occur.

Nerve injury: There is potential for facial and body nerve branch injuries resulting in: weakness of affected areas; Hyperactivity of nerve; temporary change in the smile or any facial expression; temporary numbness/tingling in the area treated.

Scarring is rare, but is a possibility if the skin surface is disruped.

Although uncommon, burns can occur.

Infection is rare, but should it occur, treatment with antibiotics and/or surgical intervention may be required. Infection can further increase the risk of scarring. Proper woulnd care is important in the prevention of infection. If signs of infection such as pain, heat, blisters, or surrounding redness develop, call the office immediately.

I understand the importance of the pre and post treatment instructions and that failure to comply with these instructions may increase the possibility of complications.

I am have read and understand the above risks associated with the procedure:

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I understand that lipo-aspiration may be used in conjunction with the Skin Tightening and Sculpting treatment, if Dr. Lentz determines it is necessary to do so. I understand that skin irregularities may occur with any lipo-aspiration treatment.

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I consent to having clinical photographs taken before, during and after my procedure. I understand that these photographs are an important part of my medical record. In addition, I consent to the use of these photographs, without my identity being revealed, for the education of future patients, professional clinical presentations and medical journals.

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The nature and effects of the procedure, the risks, the ramifications, complications, as well as alternative methods of treatment have been fully explained to me by the physician or designated person and I understand them. I am aware that this device is FDA cleared for soft tissue coagulation. The benefits of the proposed procedure, along with the probability of success have also been discussed with me. I have been given the opportunity to ask questions and have received satisfactory answers. I certify that I have read the above authorization and that I fully understand it.

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Informed Surgical Consent Forms are used to communicate information about the proposed treatment of a condition along with disclosure of risk and alternative treatment(s). The informed consent process attempts to define principles of
risk disclosure that should generally meet the needs of most patients in most circumstances.

What the surgical and office staff have discussed with you and has been included in this consent are the material risks both common and uncommon that the doctor feels a reasonable person would want to know, understand and consider in deciding if the proposed treatment of a condition is something they would like to proceed with.

However, Informed Surgical Consent should not be considered all-inclusive in defining other methods of care and risk
encountered. The staff may provide you with additional or different information that is based on all the facts in your particular case and the state of medical knowledge. Informed-consent documents are not intended to define or serve as
the standard of medical care. Standards of medical care are determined on the basis of the facts involved in an individual case and are subject to change as scientific knowledge and technology advance and as practice patterns
evolve. It is important that you read the above information contained on this and all preceding pages carefully and have all of your questions answered by the doctor before signing the consent

Signature

Date