LumiSculpt RF - Consent Form

 Marketing

We would like to contact you with special offers, related products and relevant services. If you consent for this purpose, tick you preference:

Photographs taken shall be part of the medical record and used for documentation of response to treatment. With explicit permission these photographs may also be used for educational purposes or for client information.

As part of the marketing activity (digital and/or print) we would like to use anonymously before & after photos of your treatment for use to promote this treatment.

Introduction to LumiSculpt RF

I confirm I have seen aesthetic practitioner for a medical health check prior to today's treatment.

This is an informed consent form that has been prepared to help inform you of the potential benefits and risks of LUMISCULPT RF. It is important that you read this information carefully and discuss fully with your practitioner before proceeding with treatment.

l understand the goal is to decrease the wrinkles in the treated areas, or reduce sweating in the relevant area listed above. Please sign to acknowledge you understand and consent to continuing with the procedure.

It is also important that you take as much time as you need to consider the treatment carefully, weighing up all your options before reaching an informed decision. It is essential that you are aware of your right to have a second opinion and you are encouraged to ask any questions that come to mind throughout the entirety of the process.

LUMISCULPT RF is an FDA approved technology that combines subdermal fractional radiofrequency (RF) and microneedling. The treatment aims to tighten, lift and rejuvenate skin, as well as stimulating natural subdermal collagen and elastin production. LUMISCULPT RF can be used to treat loose skin on the neck, face and body, fine lines and wrinkles, areas of hyperpigmentation, under eye rejuvenation, acne scarring and stretch mark reduction.

The possible side effects of LumiSculpt RF include but are not limited to:

RISKS: As with any procedure there are potential risks and complications associated. You must be aware of all the following risks before proceeding. You must fully discuss any questions with your practitioner.

Common side effects of LUMISCULPT RF include discomfort or pain during and after the procedure. Pain is worse particularly in areas of bony prominence or where the skin is thinner. Immediately following the procedure, the skin will feel tight, dry, swollen, and sensitive to the touch. It will also look red and feel sunburned. The sensitivity and redness will likely diminish significantly within 24 hours. Sometimes people can faint or feel faint with needles, you must tell your practitioner as soon as possible if you feel unwell during the treatment.

Other common short-term side effects include itching, discomfort, pinpoint bleeding or bruising, blisters, scabbing, and darkening of the treated area. Additionally, the skin may look and feel like sandpaper; these effects generally last 2-7 days as the treated skin flakes off and is replaced by new tissue.

Rare side effects of LUMISCULPT RF include permanent skin pigmentation changes, skin burns and or scarring which may be permanent.

I hereby indemnify the practitioner from any liability relating to the procedures that I am having. I also understand that any treatment performed is between me and the practitioner who is treating me and I will direct all post-operative questions or concerns to the practitioner.

I have been advised of the relevant information associated with this treatment and I confirm that I fully understand this advice. This includes advice about:

- the aims/motivations for having the procedure and the desired outcome

- the risks inherent in the procedure

- the risks inherent in refusing the procedure

- the risks specific to me

- the expected benefits of the treatment

- the potential disadvantages of the treatment

- alternative procedures and their pros and cons - including the option of no treatment at all

- any uncertainties about and the likelihood of success of the procedure

- any follow-up treatment that may be required

MEDICAL HISTORY & CURRENT MEDICAL CONDITIONS 

Please check any health conditions which you have ever had previously or are now experiencing. (If Yes to any of the following please detail in the box below)

Current Medical Status

By signing below l acknowledge that I have read the foregoing informed consent and agree to the treatment with its associated risks.

LUMISCULPT RF RESULTS

On average 1-3 treatment sessions are needed with treatment sessions lasting approximately 30-60 minutes. Some immediate results may be seen but results are usually seen by 3 weeks with peak results seen up to 3 months. I am aware that results vary between clients and results are dependent on many individual factors. I am aware that there is no guarantee I will achieve desired results and that multiple treatment courses may to be needed to achieve or maintain desired results. Your practitioner will offer a numbing cream to help reduce any discomfort during the procedure. Some practitioners may also offer a local anesthetic injection.

I understand that several appointments may be necessary to produce optimal results and I will be notified, in advance of each session of treatment, about the location where the next treatment session is going to take place and the identity of who is going to be involved in my care at each stage. I also understand that I will be kept informed of progress and that I can change my mind at any point.

After treatment, you should minimise exposure of the treated area to excessive sun or UV lamp exposure and extreme cold weather until any initial swelling or redness has gone away.

PRACTITIONER ONLY

I confirm that I have fully informed the patient about the risks and benefits of treatment with LumiSculpt RF and believe they understand all the information given.

They have also been informed of alternative treatment for their presenting complaint.