Body Tone Muscle Micro Current & Re Growth Device Consent

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Patient Information

Patient Name*

Body Tone Informed Consent

You are scheduled for a series of non-invasive treatments with the Body Tone. The Body Tone delivers microcurrent energy and the device is indicated for prevention and improvement of muscle atrophy, increasing local blood circulation and muscle re- education.

Your treatment provider will discuss your specific treatment needs. Recommended number of treatments is 6. The treatment is typically about 30 minutes per session, with sessions separated by at least 2 days, depending on your needs. Completing a full treatment series is necessary to maximize treatment efficacy. You may need additional treatments depending on your condition.

Prior to the treatment you are not required to do anything special. On the day of the treatment, you are advised to wear comfortable clothing which allows flexibility for correct positioning during the treatment. You will be asked to remove all jewelry and electronic devices.

I acknowledge that successful treatment outcome can be affected by smoking or excessive alcohol consumption, as well as: eating disorders or on-going medication. While no special diet is required, you are encouraged to eat healthy to help promote and maintain results.

There is typically minimal to no discomfort associated with your treatment and there is no anesthetic required. During the application you will feel intense, yet not painful contractions in the treated area. The procedure doesn’t require any recovery time. Typically, you can get back to your daily routine right after the treatment.

• There are no lifestyle restrictions following your Body Tone treatment. It is recommended to increase your water intake after treatment. • Your skin may be slightly pink to red immediately after treatment. This may last for a few hours. • I have been thoroughly and completely advised regarding the end point of the procedure. I understand that the practice of medicine is not an exact science and no results have been guaranteed. I certify that I do not have any electronic implants (pacemaker, insulin pump, LVAD, etc.).

I certify that I am not pregnant or may be pregnant and I am not breastfeeding.

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.

Body Tone Informed Consent I consent to photographs and digital images being taken and used to evaluate treatment effectiveness, for medical education, training, professional publications or sales 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.

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 hereby indemnify and hold harmless Rohrer Aesthetics, LLC and their employees, the treating technician and TNP from any and all liability, damages, cost and expenses arising from or out of the use Body Tone System for treatment of body contouring.

I have read and understand all information presented to me before consenting to treatment. I have had all my questions answered. With all of the above information understood, I am choosing to be treated with the Body Tone laser System.

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