SCULPSURE® SUBMENTAL TREATMENT CONSENT

SculpSure® delivers laser energy to heat the fat beneath your skin. The heat that is created damages the fat cells. The damaged fat cells are then eliminated by the body through your lymphatic system. When the treatment begins it will feel warm, you may also experience the sensation of pins and needles or a prickly sensation. Over time the heat sensation will increase to short periods of deep tissue heating. These sensations are normal and expected and indicate that the laser is effectively targeting and damaging the fat layer.

Your skin may be slightly pink to red immediately after treatment. This may last for hours up to days.
Following the SculpSure treatment you may experience mild to moderate swelling and tenderness that lasts approximately 2-3 (two to three) weeks, but may last longer.
You may also experience tissue firmness or nodules. Nodules typically last for days to 6 (six) months or longer, depending on the size of the nodule. While uncommon, some nodules may be permanent.
The treated area should be massaged gently two (2) times a day for several minutes.
Sleep with the head of your bed slightly elevated by using 2 (two) pillows, for several days after treatment or until all swelling has resolved.
You may use cold gel packs or Tylenol according to package instructions to help ease tenderness.
Staying well hydrated and engaging in light physical activity helps mobilize the disrupted fat for processing through the lymphatic system.
We encourage you to drink at least 8 (eight) glasses of water a day.

I understand that the practice of medicine is not an exact science and no results have been guaranteed. I acknowledge that the results may not meet my expectations. I certify that no guarantees have been made by anyone regarding the procedure(s) that I have requested and authorized.*

YESNO

Initials*

Initial

I have been informed that firmness, hardness, nodules, redness, tenderness, swelling, pain, and bruising, are the most common side effects. Other less common side effects which may occur are itching, skin contour irregularities, dimpling, hyperpigmentation/hypopigmentation, asymmetry, unmasking of platysmal bands, necrosis, changes in skin laxity, numbness, blister or burn.*

YESNO

Initials*

Initial

I consent to photographs and digital images being taken and used to evaluate treatment effectiveness, for medical education, clinical training, professional publications or sales and marketing purposes. No photographs or digital images revealing my identity will be used without my written consent. If my identity is not revealed, these photographs and digital images may be used, shared, and displayed publicly for such stated purposes without my permission.*

YESNO

Initials*

Initial

Before and after treatment instructions have been discussed with me. The procedure, potential benefits and risks, and alternative treatment options have been explained to my satisfaction.

I consent to photographs and digital images being taken and used to evaluate treatment effectiveness, for medical education, clinical training, professional publications or sales and marketing purposes. No photographs or digital images revealing my identity will be used without my written consent. If my identity is not revealed, these photographs and digital images may be used, shared, and displayed publicly for such stated purposes without my permission.*

YESNO

Initials*

Initial

I have read and understand all information presented to me before consenting to treatment. I have had all my questions answered.

Consent for treatment of*

First Name*

Last Name*

Email*

example@example.com

Date*

Date

Provider Name*

First NameLast Name

Provider Signature*

Date*

Date

SCULPSURE SUBMENTAL CONSENT