SKIN TYPE ASSESSMENT
Description of the Procedure
Velashape III is a new non-invasive treatment that uses a combination of technologies to contour your body and reduce the appearance of cellulite. Vacuum technology manipulates your skin while infrared light and bi-polar radio frequency energies gently heat fat cells and surrounding tissue.
Treatment with this device is contra-indicated for patients with any of the following conditions:
* Although not recommended, these conditions may be treated at the discretion and under the full responsibility of the medical director/physician. In such a case, a small area should be treated and assessed a few days later to determine if the patient will tolerate the treatment without developing adverse effects.
Potential Risks & Side Effects
Certain side effects may be experienced during treatment or shortly afterwards, usually as a result of improper use of the system. Although these side effects are rare and temporary, they should be reported immediately to a physician for proper treatment. These are the side effects that may appear in the treatment area:
I understand that the VelaShape is a device used for improving the appearance of cellulite and reducing circumferences and that it may also be therapeutic for improving circulation and muscle aches in the treated areas. I understand there is a possibility of short- term effects such as discomfort, reddening, blistering, scabbing, temporary bruising and temporary discoloration of the skin, as well as rare side effects such as scarring and permanent discoloration.
These effects have been fully explained to me patient's initials* (patient's initials). I have also been advised of the Pre-and Post-treatment care which are as follows: PRE-TREATMENT INSTRUCTIONS1. Avoid the sun for a minimum of 7 days before treatment 2. Hydrate, hydrate, hydrate! For maximum results, stay hydrated and drink the recommended 64oz of water per day to help move the lymph and achieve optimal results. The machine will not achieve the desired affect if the body is dehydated.POST-TREATMENT INSTRUCTIONS1. Avoid the sun for a minimum of 7 days after treatment 2. Make a followup appointment within 1-2 weeks of treatment. 3. For maximum results, exercise for 30 mins a day to help move the lymph. 4. Follow up the VelaShape treatment with one of AAC’s body treatment for lymphatic drainage.I understand that clinical results may vary depending on individual factors, including but not limited to medical history, skin type, patient compliance with pre- and post-treatment instructions, and individual response to treatment.I understand that treatment with the VelaShape involves a series of treatments and the fee structure has been fully explained to me patient's initials* (patient's initials).I certify that I have been fully informed of the nature and purpose of the procedure, expected outcomes and possible complications, and I understand that no guarantee can be given as to the final result obtained. I am fully aware that my condition is of cosmetic concern and that the decision to proceed is based solely on my expressed desire to do so. I confirm that I have informed the staff regarding any current or past medical condition, disease or medication taken.I consent to the taking of photographs and authorize their anonymous use for the purposes of medical audit, education and promotion.I certify that I have been given the opportunity to ask questions and that I have read and fully understand the contents of this consent form.This consent form is valid until all or part is revoked by me in writing.I patient's full name* (full patient name) authorize Anti-Aging Centers of Connecticut, LLC and its designated staff to perform Velashape treatment on my body.