Radio Frequency Consent Form

Patient’s Name:

File No.:

DOB:

Mobile Number:

Visit Date:

Registration Time:

Doctor Name:

Radio Frequency Consent Form

• I understand that RF treatments cannot prevent future skin aging. Multiple treatments are required and there is no guarantee that the wrinkles or sagging skin will be completely addressed. Results are individual. While it is expected to have a 40% to 50% improvement in the treated area after a completed series of weekly treatments, it is impossible to guarantee results. Some people exceed our expectations and some people respond below expectations. Weekly treatments present the best outcome in most individuals.

• I agree pre/post treatment photographs will be obtained, for the sole purpose of future reference to compare my results. Photos will be kept confidential and not will be used for other purposes without permission.

• I understand that there is a possibility of rare side effects such a scarring and permanent discoloration as well as short term effects such as reddening, swelling, mild burning, blistering, burns, scabbing or temporary discoloration of the skin. These effects have all been fully explained to me and my questions have been answered. I accept the risks and complications of the procedure.

I understand and agree that I am financially responsible for the payment I made for that any amount I paid for the sessions or procedures I booked it will only be valid up to 3 months from the date I made the payment. I understand that I need to utilize the sessions or procedures within 3 months period. I agree that my payment made is non-refundable or non-transferable post this period.

I declare that I have read and fully understood all points in this consent and that all of my questions were answered to my satisfaction and I take the full responsibility of my decision in this consent.

Patient Name & Signature :

Doctor/Therapist Name & Signature :

Witness Name & Signature :

Parent or Gaurdian Name (if patient is minor) :

Date :

Consent to be photographed and published

I, , consent to be photographed and published on Social media, by while before and after the procedure. I further authorize that the photographs may be published for any purpose and in any form.

Patient Name & Signature :