Pelleve Consent Form

Pellevé RF Wrinkle Reduction Treatment
Client Informed Consent Form

I, _______________________________ (print name), authorize Dr. Shirat Ling and/or staff member to perform Pellevé RF wrinkle reduction treatment. I understand that the procedure is purely elective. As with any elective cosmetic procedure, I understand that results cannot be guaranteed. For best results, I have been informed that a timed treatment regimen of multiple treatments is necessary.
Pellevé wrinkle reduction system has been cleared by the FDA for the nonablative treatment of mild to moderate facial wrinkles, rhytids. All patients are different and exact results of this cosmetic procedures and treatments cannot be predicted or guaranteed. Studies indicate that greater than 85% of patients still have observable results six months after treatment.
Precautions prior to treatment:
I should not be treated if I am currently taken Accutane, or other photosensitizing medications, or have a medical condition that increases photosensitivity without approval from my provider.
If I am prone to HSV or cold sores in the treated area, it is my responsibility to inform my treatment provider, as an anti-viral medication can be prescribed prior to the procedure
What I can expect during treatment
Slight discomfort may be experienced with warmth and heat
Discomfort is typically mild and temporary during the procedure and localized within the treatment area.
I will need to provide feedback to the treatment provider. Therefore, no anesthetic (local, oral, or systemic) should be used prior to or during the treatment
I understand that complications are very uncommon but possible. Common side effects include:
Temporary mild swelling
Redness similar to a mild sunburn
May persist for a few hours to 3-5 days or longer
Inadequate or impaired feedback may lead to blisters or injury to the skin
Sun exposure, or use of tanning beds, tanning cream, spray, or sun exposure and not adhering to the post care instructions provided to me will greatly increase my chance of complications
For women of childbearing age: By signing below I confirm that I am not pregnant and do not intend to become pregnant anytime during the course of treatment. Furthermore, I agree to keep Dr. Ling and staff informed, should I become pregnant during the course of treatment.
When completing the medical questionnaire, I have answered the personal medical history questions fully and to the best of my ability. I certify that I have read the above consent and I fully understand it. The nature and purpose of the procedure, the possible benefits, complications and risks, the alternatives to the procedure, and the risks and benefits of those alternatives have been explained to me in a language and using terminology that I understand. I fully understand that this is an elective aesthetic procedure, and that there is no emergency of medical condition that requires that I have the Procedure. I understand that I have the right to refuse treatment. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement.
I authorize Dr. Shirat Ling, or her medical staff to perform this procedure. I understand and agree that all services rendered to me are charged to me directly and that I am personally responsible for full payment at the time of service. I acknowledge that no guarantee, warranty, or assurance has been made to me as to the results that may be obtained. No refunds will be given for treatments received. All prices are subject to change without prior notice.
I release and forever discharge and forever hold harmless Dr. Shirat Ling, Innate Beauty, and its associates, agents, officers, and shareholders from any and all claims, damages, or legal actions arising from or connected in any way with the procedures and conduct used to apply these procedures by Innate Beauty and its associates, agents, and representatives in the future. I certify that I am a competent adult of at least 18 years of age. This consent form is freely and voluntarily executed and shall be binding upon my spouse, relatives, legal representatives, heirs, administrators, successors and assigns. This constitutes the full disclosure and supersedes any previous verbal or written disclosures.
Severable clauses: if any clause in this consent is found invalid or unenforceable by a court of law, the remainder of this consent will not be affected and all other provisions of this consent will remain valid and enforceable.
Signor agrees that a photocopy of this signed and dated document will act in the same capacity as an original and legally-binding document.
*Due to the fact that, so much of the result is dependent upon the compliance with aftercare to the utmost strictness, therefore the result is largely out of the control of Dr. Ling and her staff. The patient waives the right to sue. Your result is within your own hands; aftercare is a crucial element, and is over 50% dependent on following proper aftercare. There is no way Dr. Ling can control the outcome.*

Patient signature: __________________________________________Date: _______________________________

Witness signature: _________________________________________Date: _______________________________