Consent - UltraShape

Simply Skin Las Vegas

Client Care Treatment Instructions - UltraShape Power
Name*

First NameLast Name
PRE-TREATMENT INSTRUCTIONS
- You MUST cease all bleaching, plucking/tweezing, waxing, threading/stringing, and electrolysis for 4 weeks prior to treatment.
- You may be asked to stop any topical medications or skin care products prior to treatment
- Avoid sun exposure and sun bed for 2 weeks prior to treatment. RECENTLY TANNED SKIN CANNOT BE TREATED. If treated within two weeks of active (natural sunlight or tanning booth) tanning, before or after treatment, you may develop burns that heal in hypo-pigmented white spots, and this may not clear for 2-3 months. In extreme cases, this may be permanent
- The use of self-tanning products/bronzers must be discontinued one week before treatment. Any residual self-tanner must be removed prior to treatment
- Exfoliate and shave the area to be treated one day prior to treatment
- If you have had a history of perioral or genital herpes simplex virus, antiviral therapy is recommended in order to prevent a breakout. Follow the directions for your particular antiviral medication
- The treatment area should be clean of any perfume, deodorant, makeup, lotions, sun block, or any other chemical or skincare products
- Wear loose fitting, easily washable clothes, as the area may be tender directly post-treatment. Ultrasound gel is applied and used during treatment, which may get on your clothes.
- VERY IMPORTANT: Drink half of your body weight in ounces of water for two or three days prior and post treatment – the UltraShape procedure breaks down fat cells so that they may be metabolized by the body and excreted. When your body is fully hydrated, this metabolic process is enhanced. Also, ultrasound energy requires a well-hydrated body for effective conductivity.
- Avoid Alcohol for 72 hours prior to treatment
- Avoid eating a large meal or drinking excessive liquids before treatment. The UltraShape procedure involves pressure on the abdomen and requires you to be still for the duration of the treatment.
INTRA-TREATMENT CARE
- At the beginning of every treatment session, we will review your medical status, and ask if there have been any changes. Please remember to inform us of any changes such as health, medications, and sun exposure. Changes may alter the effectiveness of treatment and may cause side effects and/or complications
- The skin is cleaned prior to treatment
- The technician may line the area with a white pencil in order to effectively treat you. This will wash off.
- Safety considerations are important during the procedure
- Some clients may feel a slight discomfort or pain after treatment
POST-TREATMENT INSTRUCTIONS
- Following your UltraShape session, you are free to resume regular activities. We generally recommend mild exercise post procedure to assist the lymphatic system in metabolizing the fat released. Any residual soreness you feel should be over within 48 to 72 hours.
- Following treatment, we suggest that you follow a clean, healthy, balanced diet and avoid large meals that might expand your stomach – instead eat five or six small meals per day for the two or three days following treatment.
- Avoid alcohol for 72 hours post treatment to allow for rapid clearing of fat content and toxins released during treatment.
- Immediately after the treatment, there may be swelling and redness in the areas that are treated. The redness may last up to 2-3 days. An antihistamine may be used, if necessary. Please be mindful that some antihistamines may cause drowsiness and should be avoided if driving or operating heavy machinery.
- If the redness lasts for more than 72 hours, or if any blistering or breakage of the skin occurs, please contact us immediately.
- Bruising and broken blood vessels may appear and will go away in time
- Avoid sun exposure for two weeks pre/post to reduce the chance of dark or light spots. Use sunscreen SPF 40 or higher at all times throughout the treatment and for 2 weeks following
- Avoid tanning of any sort during the entire course of treatment.
- Avoid picking or scratching the treated skin. During your treatments, DO NOT exercise any other skin rejuvenation, CO2, IPL, Laser, or any other methods or products on the treated area.
- NO waxing, NO threading/stringing, NO sugaring, NO plucking/tweezing, NO depilatory creams (nair, veet, etc.). ONLY shaving, if necessary, please to avoid excess irritation
- Keep consistent appointments. For optimal results, schedule 3 sessions, with two weeks between each session.
- Please do not hesitate to call or text us at (702) 823-0852 if you have any questions or concerns
ACKNOWLEDGMENT: I acknowledge that I have had the opportunity to review the Client Care treatment Instructions prior to treatment.*

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Client Signature
If minor, Parent/Legal Guardian Signature

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Simply Skin Las Vegas

Client Consent, Rights, Responsibilities
We are committed to serving you with compassion, care, skill, and respect. As one of our clients, you have choices, rights, and responsibilities.
Client's Name*

First NameLast Name
I hereby authorize Simply Skin Las Vegas, its employees/agents/clinicians to perform UltraShape treatments on me. Treatment Sites include: Abdomen, Flanks, Inner/Outer Thigh and Arms

The purpose of this procedure is to use the UltraShape device for the cosmetic removal of fat to the treated areas, which I hereby consent to be a patient receiving treatment.

UltraShape is focused, pulsed mechanical ultrasound that permanently destroys fat cells in the treated area without causing damage to tissue and adjacent structures.

I understand that the treatment is purely elective. Alternative methods to (whether more effective or ineffective) are Lasers and Surgery. I understand that certain complications are rare, but possible.

Side effects are rare but can include swelling, bruising, minor burns and blisters on or around the treated area, temporary discoloration of the skin, as well as the possibility of rare side effects such as burn, scarring and permanent discoloration.
The procedure may result in the following side effects or adverse experiences, and may carry some risks:
- DISCOMFORT – Some discomfort and blistering (although minimal and rare) may be experienced during treatment
- REDNESS/SWELLING/BRUISING – Short-Term/temporary redness (erythema), swelling (edema), and/or mild sunburn-like effects of the treated area is may occur. There also may be slight bruising.
- SKIN COLOR CHANGES – There is a possibility that the treated area may become either darker (hyper-pigmentation) or lighter (hypo-pigmentation). These conditions usually resolve within 3-6 months, but permanent color change is a rare risk. Compliance with the aftercare guidelines and avoiding sun exposure before and after the treatment reduces the risk of color change.
- WOUNDS – Treatment can result in burning or blistering of the treated areas, in extremely rare cases. If any of these occur, please contact our office immediately.
- INFECTION/BREAKOUTS – Infection is a possibility whenever the skin surface is disrupted, although proper wound care should prevent this. If signs of infection such as pain, heat, or surrounding redness develop, please call our office immediately. If you have had a history of perioral or genital herpes simplex virus, antiviral therapy is recommended in order to prevent a breakout.  Follow the directions for your particular antiviral medication  
- SCARRING – Scarring is a rare occurrence, but it is a possibility if the skin surface is disrupted. To minimize the chances of scarring, it is IMPORTANT that you follow all post-treatment instructions provided by your healthcare staff. Compliance with the aftercare guidelines and avoiding sun exposure before and after the treatment reduces the risk of scarring.
- ALLERGIC REACTIONS – In rare cases, local allergies have been reported.
I am aware of the possible complications/risks involved with the procedure and subsequent healing period. *

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I fully understand that it is impossible to make guarantees regarding the outcome of any cosmetic/medical treatment and/or procedure. 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 acknowledge that no guarantees, either expressed or implied have been made to me regarding the outcome of any treatments and/or procedures. *

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I understand that I am financially responsible for all amounts due for services rendered at the time of the treatment. I also authorize the release of information to a licensed physician of the facility’s choosing for the purposes of professional interpretation and establishment of treatment recommendations.*

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I understand that my procedure may involve a series of treatments*

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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.*

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I HAVE THE RIGHT TO:
- Be treated with dignity and respect
- Know the name(s) and professional status of the person(s) serving you
- Privacy
- Confidentiality of your records
- Receive accurate information about your health-related concerns
- Know the effectiveness, possible side effects and problems of all forms of treatments
- Participate in choosing a form of treatment
- Receive education and counseling
- Consent to, or refuse any care or treatment
- Review your medical record with your clinician
- Amend your medical records
- Receive any information about services
I ALSO HAVE THE RESPONSIBILITY TO:
- Seek medical attention promptly
- Be honest about your medical history
- Ask about anything you do not understand
- Follow health advice and instructions
- Report any changes in health or medication
- Respect our policies
- Seek care during normal business hours and to provide useful feedback regarding our services and policies
If applicable, at the time of treatment, I can neither be pregnant nor nursing*

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I have provided my past and current medical history and medications*

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I consent to the taking of photographs during the course of my laser therapy for healthcare records – we must be able to document any reactions, pre-existing marks in the area, etc. These will be unidentifiable and will remain with your medical records*

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I consent to using my photographs for medical education and/or marketing purposes

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ACKNOWLEDGMENT: I understand the information given to me and the risks that have been outlined. I will be given the opportunity to ask questions about the procedure during my consultation and will not proceed with treatment until my questions regarding the procedure and the risks associated have been answered satisfactorily. 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 with a complete understanding of the risks. *

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Client Signature
If minor, Parent/Legal Guardian Signature

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Simply Skin Las Vegas

Simply Skin Las Vegas