Pixel8 Consent 2020

Consent for Radio Frequency Micro-Needling
I, First Name Last Name authorize and consent to the treatment for skin tightening with the PIXel8 Radio Frequency Micro Needling System. I have been advised by Provider Name of the purported advantages and disadvantages associated with this treatment Initials
I understand that treatment with this system varies from patient to patient and that that morethat 1-treatment may be required.
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Although rare, adverse outcomes such as skin texture changes and scarring can occur.
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No guarantees have been made to me regarding the outcome of the treatment or any improvements in my skin condition due to the procedure.
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I understand that the possible benefits are the tightening of loose skin.
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I certify that I do not have any metal implants in the area being treated.
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I certify that I do not have any electronic implants (pacemaker, insulin pump, etc.).
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I have been given the opportunity to ask questions and have received satisfactory answers to those questions.
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I hereby authorize the taking of photographs. These photographs may be used to demonstrate the results of this device procedures
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I hereby indemnify and hold harmless Rohrer Aesthetics, LLC and their employees, the treating technician, and Type a label New Skin and Body Aesthetics from any and all liability, damages, cost, and expenses arising from or out of the use of PiXel8 - Radio Frequency Micro Needling System for treatment of skin tightening blank
With all of the above information understood, I am choosing to be treated with the PiXel8- Radio Frequency Micro Needling System.
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Consent for Radio Frequency Micro-Needling