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*(NOTE: THIS PATIENT INFORMED CONSENT TEMPLATE IS PROVIDED “AS IS” AND IS INTENDED FOR INFORMATIONAL PURPOSES ONLY. THIS TEMPLATE MAY NOT MEET ALL STATE AND FEDERAL LEGAL OR REGULATORY REQUIREMENTS FOR USE WITH PATIENTS. PHYSICIANS USING THIS TEMPLATE ARE RESPONSIBLE FOR ENSURING THE INFORMED CONSENT FORM USED WITH PATIENTS MEETS ALL APPLICABLE STATE AND FEDERAL LEGAL AND REGULATORY REQUIREMENTS, AND ARE ENCOURAGED TO CONSULT WITH THEIR ATTORNEY.)

I hereby authorize Sarah O’Donnell to perform a VirtueRF treatment on me. I understand that this procedure may be used to for: RF Microneedling in to treat wrinkles and other areas of concern. I understand that I may require several treatments to obtain a significant, long-term results. I understand I may experience redness, dryness, sloughing of the tissue, mild to moderate sunburn sensation and/or bleeding post treatment. I understand all the potential side effects, as discussed with me prior to treatment. I understand that genetics, hormones, medication and skin color may interfere with the ability to perform an effective treatment.

The procedure may result in the following adverse experiences or risks: DISCOMFORT/PAIN – Some discomfort and/or pain may be experienced during treatment, but is unlikely. REDNESS/SWELLING/BRUISING – Redness (erythema) or swelling (edema) of the treated area is common and may occur. There also may be some bruising. HYPOPIGMENTATION / HYPERPIGMENTATION: (Changes in skin Color): – During the healing process, there is a slight possibility that the treated area may become either lighter (hypopigmentation) or darker (hyperpigmentation) in color compared to the surrounding skin. This is usually temporary, but, on a rare occasion, it may be permanent. WOUNDS – Treatment can result in burning, blistering, or bleeding of the treated area(s), but is unlikely. SUN EXPOSURE / TANNING BEDS / ARTIFICIAL TANNING – Should be avoided because they may increase risk of side effects and adverse events. INFECTION – Infection is a possibility whenever the skin surface is disrupted, although proper wound care should prevent this. If signs of infection develop, such as pain, heat, or surrounding redness, please call our office 325-277-1132.

SCARRING – Scarring is a rare occurrence, but it is a possibility if the skin surface is disrupted. To minimize the chances of scarring, it is IMPORTANT that you follow all post-treatment instructions provided by your healthcare staff.

I acknowledge the following points have been discussed with me: Potential benefits of the proposed procedure, including the possibility that the procedure may not work for me Alternative treatments and my options Reasonably anticipated health consequences if the procedure is not performed Possible complications/risks involved with the proposed procedure and subsequent healing period For women of childbearing age: By signing below I confirm that I am not pregnant and do not intend to become pregnant anytime during the course of treatment.

Photographic documentation will be taken. I hereby authorize the use of my photographs for teaching purposes.

ACKNOWLEDGMENT

BY MY SIGNATURE BELOW, I ACKNOWLEDGE THAT I HAVE READ AND FULLY UNDERSTAND THE CONTENTS OF THIS INFORMED CONSENT FOR THIS TREATMENT, AND THAT I HAVE HAD ALL MY QUESTIONS ANSWERED TO MY SATISFACTION BY MY HEALTHCARE TEAM.

 

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