MORPHEUS8 CONSENT FORM

Patient’s Name:
File No.:
DOB:
Mobile Number:
Visit Date:
Registration Time:
Doctor Name:

MORPHEUS8 CONSENT FORM:

Under 18 years of
age Pregnancy or
nursing
Pacemaker or internal defibrillator or any electronic implant such as glucose monitor
Permanent implant in the treated area such as metal plates and screws, silicone implants or an injected chemical
substance Current or history of cancer , especially skin cancer, or pre-malignant moles
Impaired immune system due to immunosuppressive diseases such as AIDS and HIV, or use of immunosuppressive medications
Sever concurrent conditions such as cardiac disorders, epilepsy, uncontrolled hypertension, and liver or kidney
diseases A history of diseases stimulated by heat, such as recurrent Herpes Simplex in the treatment area
Any active condition in the treatment area, such as sores ,psoriasis, eczema and rash as erll as excessively freshly tanned skin
History of skin disorders such as keloid scarring, bnormal wound healing, as erll as very dry nd fragile skin
Any medical condition that might impair skin healing
Poorly controlled endocrine disorders, such as diabetes or thyroid dysfunction
Any surgical, invasive, ablative procedure in the treatment area in the last 3 months or before complete healing
superficial injection of biological fillers in the last 6 months, or Botox in the last 2 weeks
Use of Isotretinoin ( Accutane ) within 6 months prior to treatment

Informed Consent for MORPHEUS8 Treatments

This form is designed to give you the information you require to make an informed choice of whether or not to undergo treatment with MORPHEUS8 technology. If you have any questions before your treatment please feel free to ask. I hereby authorize Dr. and/or such assistants as nay be selected to perform the MORPHEUS8 procedure.

The physician obtained my medical history and found me eligible for treatment. I have received the following information about the technology:

MORPHEUS8 technology utilizes fractional radio frequency (RF) indicated for facial/neck as well as small body areas.

The MORPHEUS8 treatment improves the appearance of loose, sagging skin/areas by reaching deep into the tissue to heat and tighten, controlled by the practitioner.

It can also help improve skin texture & condition, lines , wrinkles, and depressed scars, such as acne scars.

The treatment induces skin rejuvenation by heating of the dermis which stimulates collagen and elastin generation

The treatment requires anesthesia that involves topical cream, injections, or sedation according to the treatment parameters and the physician discretion.

I understand that taking the treatment course is mu choice and that I am free to withdraw at any time, without giving any reason.

There may be alternative procedures or methods of treatment, such as fractional lasers for ablation (CO2) and lasers, IPL or RF based systems for skin rejuvenation. As of today, there are no systems in the market that can address the variety of lesions that MORPHEUS8 does. Details were explained to me.

I was told about the downtime of treatment: local pain, skin redness (erythema) , serlling (edema) and possible break outs after treatment. I was told about possible side effects of the treatment: damage to the natural skin texture (crust, blister, burn) , change of skin pignentation ( hyper - or hypo- pigmentation), and scarring. Although these effects are very rare and expected to be temporary.

Redness and swellinf usually last a day or two, but may last longer depending on the patient and treatment parameters used, and are part of a normal reaction to the treatment . Burns and resulting pigmentation change and scarring are very rare and may happen in dark skin that is not taken care according to instructions, or if post care instructions are not follwed.

Tiny scabs may appear on the face for a few days as part of a normal healing, however make-up may be applied as soon as 1-3 days after the session to mask them and residual redness. Any adverse reaction should be reported immediately.

I understand that the treatment usually involves a few treatnents (1-3) , a few weeks apart ( 3-6 weeks) , according to treatment parameters and individual response.

I understand that I have to comply with treatment schedule, otherwise results may be compromised.

I recognize that during the course of the procedure unforeseen conditions may necessitate different procedures than this above and I authorize the physician or assistants to perform such other procedures if they find them professionally desired.

I understand that not everyone is a candidate for this treatment and results may vary. Therefore , there is no guarantee as to the results that may be obtained.

 

My signature below constitutes my acknowledgement and understanding of all this information, and i hereby authorize and direct the doctor/nurse or therapist to perform the treatment on me. I agree that healthcare providers involved in my care at this facility eill access ny health information through the Health Information Exchange System (NABIDH) in accordance with the laws of the United Arab Emirates, Emirate of Dubai Legislation and Dubai Health Authority Policies.
Patient Name & Signature :   

Health Professional Declaration:
I have adequately explained to the patient about the procedures along with risks, adverse effects and the standard alternatives that are available for the procedure. I have [ermitted time and opportunity for the patient to ask questions and all questions have been answered to myh knowledge.
Doctor/Therapist Name & Signature :   

Witness Statement:
I have accurately read or witnessed or witnessed the accurate reading of the consent form to the patient and the individual has had the opportunity to ask questions. I confirm that the individual has given consent freely.
Witness Name & Signature :     

Parent or Gaurdian Name (if patient is minor) :

Date :