- I hereby authorize the Medical Staff at New Skin and Body Aesthetics to treat me for Vaginal Rejuvenation using the Exilis Ultra Femme 360.
- I understand the results may vary from person to person and that an exact result cannot be predicted.
-
I understand that completing a full treatment series, administered 7-14 days apart, is necessary to maximize treatment efficacy.
-
I understand that good dietary habits, sufficient intake of water and light physical activity are beneficial and may optimize results.
-
I understand there are certain risks associated with Exilis Ultra Femme 360 treatments and they include but are not limited to:
- Swelling
- Redness
- Tissue tenderness
- Brusing
- Light Spotting
- Dry skin
Although unlikely, adverse effects such as skin burns and blisters may occur.
-
I understand that the treatment may involve risks of complications or injury from both known and unknown causes, and I freely assume these risks.
-
I confirm that I do not have an inserted pacemaker, internal defibrillator, vaginal implants, impaired immune system or metal implants.
-
I confirm that I have an IUD in place, which is non-metal. I confirm that I was highly advised to remove my IUD prior to the start of treatment. I confirm that I understand that there is a risk of dislodging my IUD during treatment, and by signing this consent form, I acknowledge that I do not hold New Skin and Body Aesthetics, or their staff responsible for any complications that may occur as a result of leaving my IUD intact. Complications may include, but are not limited to the following: Dislodging the IUD, pregnancy, possible unknown injury related to the use of Radio Frequency with an IUD intact.
- I am currently not pregnant or breastfeeding. I do not have any other contraindications listed in the Operator’s Manual.
- I have been advised to increase my water intake at least 48 hours before and for 4 days after treatment. On the day of treatment, I will need to wear comfortable clothing and may have to remove all jewelry. The area(s) to be treated will be marked and oil or gel may be applied. The treatment area(s) will be exposed to various degrees of heat from the Exilis Ultra 360. I may experience intense heat.
- I agree to before and after treatment photographs, measurements, and weight as this will help in the evaluation of the results of the treatment.
- I certify that I have read this entire document and that I agree with all provisions. I certify that
I have had the opportunity to ask questions and these questions have been answered in full
to my satisfaction. I fully understand the treatment conditions, the procedure and possible side effects.
I hereby give my consent and authorization and release this establishment and its agents of any claims that I have in the future connection with the described treatment.