ULTHERAPY CONSENT FORM

TIMELESS BEAUTY AESTHETICS, LLC

The following points of information have been specially discussed and I have had the opportunity to ask any questions concerning this information:

PATIENT CONSENT

The following points of information have been specifically discussed and I have had the opportunity to ask any questions concerning this information:

• The Ulthera® System delivers a low amount of focused ultrasound energy to the skin. The heat from the
  ultrasound stimulates new collagen to form. I understand that there can be discomfort during the treatment
  when the ultrasound energy is delivered. I have discussed with my practitioner the options available to me
  to optimize my comfort during the procedure.
  

 

• Immediately following Ultherapy®, the skin may appear red for a few hours. It is not uncommon to experience slight swelling for a few days following the procedure or tingling/tenderness to the touch for
  days to weeks following the procedure, but these are mild and temporary in nature.

• Occasional temporary effects may include bruising or welts, which resolve in hours to days, or numbness in a select area, which resolves in days to weeks.

• As with any medical procedure, there are possible risks associated with the treatment. There is a remote risk of a burn that may or may not lead to scarring (either of which will respond to medical care), or
  temporary nerve inflammation, which will resolve in a matter of days to weeks. Temporary local muscle
  weakness may result after treatment due to inflammation of a motor nerve. Temporary numbness may
  result after treatment due to inflammation of a sensory nerve.

• It has been explained to me that the results vary from patient to patient, and, occasionally, the collagen building on the inside that helps counter the effects of gravity does not have a visible effect on the outside. I understand that results will unfold over the course of 3 to 6 months and that some patients may benefit from more than one treatment. 

• I grant permission and consent to Timeless Beauty Aesthetics for the use of the following photograph(s) as identified below for presentation under any legal condition, including but not limited to: publicity, copyright purposes, illustration, advertising, and web content.

I now authorize TIMELESS BEAUTY AESTHETICS to begin my Ultherapy treatment.

ULTHERA EMPLOYEE STATEMENT: I have fully explained to the patient above, the nature and purpose of the Ultherapy treatment and the potential risks associated with that treatment. I have asked the patient if he/she has any questions regarding this treatment or the risks and have answered those questions to the best of my ability. I also acknowledge that I have read and understand the prescribing information listed above.