Informed Consent for Cellulite & Body Contouring Treatments Viora/ Diamond/ Ultrashape Power

"*" indicates required fields

Patient Information

Patient Name*

Informed Consent for Cellulite & Body Contouring Treatments Viora/ Diamond/ Ultrashape Power

The purpose of this procedure is to diminish the appearance of cellulite in the areas indicated above. The procedure requires more than one treatment and may produce some reduction in the appearance of cellulite. The total number of treatments will vary between individuals. On occasion there are patients that do not respond to treatments so the outcome cannot be guaranteed. Alternative methods are available from dermatologists or plastic surgeons.

Please do know we approve our BODY BRONZE spray tanning as other brands will forfeit your voucher, as we do not promote pre-tanning of any kind on area site. Please reschedule or wait `til after vacations, and or events. As this will result of injured skin and or adversities.

Pre-Post Care: Unprotected sun exposure or use of tanning beds, creams in areas to be treated. We might request rescheduling and or no treatment as you are taking risk of injury, Pregnancy, Menstrual dysfunction, use of mechanical epilation less than 4-6 weeks prior to treatment for patients seeking hair removal, Allergies, History of Seizures, Medications, History of keloid and hypertrophic scar formation Active infections/immunosuppression. Open lesion, Herpes 1 or 2 within the treatment area, Tretinoin (Retin A or Renova)3 Oral isotretinoin (Accutane) within the preceding six months. (Dr. Note will be required before Tx is started) No sun-tanning or self-tanners 8 weeks prior to treatment Includes spray tans, tanning lotions, tanning beds, sun exposure, etc. Avoid treatments that may; irritate the skin for 4 weeks prior to treatment (waxing, depilatories, eke.) Notify clinic with any changes to your health history or medications since your last appointment History of herpes or cold sores may require an anti-viral prescription prior to treatment if treating in the area that breakouts occur.

Post Laser Tx Only:

A mild sunburn like sensation is expected. This usually lasts 2-24 hours but can persist up to 72 hours. Mild swelling and or redness may accompany this, but usually resolves in 2-3 days. Apply Aloe Vera and or ice cold packs to the treatment area for 10-15min every hour for the next four hours, or as needed. An oral, non-steroidal anti- inflammatory, such as Acetaminophen may be taken to reduce discomfort. In some cases, prolonged redness or blistering may occur. Aloe Vera may be applied and SPF 45/50 to affected area twice a day until healed. Bathe or showers as usual. Treated areas may be temperature sensitive, Cool showers or baths will offer relief. Avoid aggressive scrubbing and use of exfoliates. Scrub brushes and loofah sponges until the treatment area has returned to its pre-treatment condition. Until redness has completely resolved, avoid all of the following, no harsh cosmetics to treated area, swimming especially in pools with chemicals, such as chlorine. Hot tubs/Jacuzzis, Activities that cause excessive perspiration.

Viora Cellulite Reduction: There several factors which are involve in the formation of and contribute to the appearance of cellulite: Impairment or lymphatic drainage leading to the accumulation of lymphatic fluid waste and edema. Reduced venous flow blood microcirculation and metabolism of the tissue which ultimately deprive cells of oxygen and nutrients. Increase in rigid and inflexible collagen fibers viola’s proprietary & Technologies. With multi-RF channels and vacuum suction, addresses these factors combining deep tissue heating though bi-polar / multi polar RF and Vacuum action. These technologies help to reduce cellulite by treating the symptoms effectively and safely. This treatment provides consistent long-term results, primarily in the appearance of firmer and tighter skin. The RF energy heats the hypodermal layers to enhance blood microcirculation, in turn increasing fat cell metabolism leading to fat volume reduction. The heating effect in the dermal layers also contributes to connective tissue remodeling which tighten the skin for a longer period of time.

Diamond Laser Lipo – (1 x wkly) 3-Diode Laser built in one machine for Stretchmarks, Contouring & Lymphatic Drainage, Customizable for any client.

Ultra-Shape Power -(2 Weeks) Ultra Shape’s gentle ultrasound energy destroys the walls of fat cells in your body and releases that fat in the form of triglycerides. Those triglycerides are then processed through the liver and eliminated from the body naturally. Meanwhile, the surrounding tissue, nerves and muscles are left completely unharmed.

Body Sculp-(4-6 weeks) What is BodySculp? BodySculp is a laser-based, noninvasive, nonsurgical cosmetic body treatment that is used to target and reduce or eliminate fat. It works for both men and women and on a variety of body types. The procedure requires no incisions or anesthesia. However, the patient may experience some minimal discomfort. A procedure takes approximately 25 minutes and can target up to 4 areas at once and there is little to no recovery time. How does BodySculp work? BodySculp is a type of lipolysis. Lipolysis is a fat-eliminating process. BodySculp uses laser technology to “melt” fat cells away. What does BodySculp do? BodySculp includes 4-treatment applicators that connect to a hands-free laser belt. The applicators dissipate a 1060nm wavelength of energy and the laser energy will heat to eliminate fat cells. The BodySculp is FDA cleared for noninvasive lipolysis in the following areas: • upper abdominal area • lower abdominal area • flanks Patients who are treated with the BodySculp must have a body mass index (BMI) of 30 or less. BodySculp is not a weight loss treatment and is not an option for people with obesity. Preparing for BodySculp Treatment When discussing the procedure with your patient, you should communicate which areas of their body that they are interested in treating. At least 3 sessions are required to reach their goals. Based on licensing rules in your state, the licensed practitioner may be a: • doctor • physician’s assistant • nurse practitioner • nurse • aesthetician The first BodySculp consultation may take place right before the treatment. Be prepared to discuss the patient’s medical history and what medications they are currently on. To minimize the chance of bruising, the patient should be told to avoid blood thinners, Ibuprofen or aspirin a few days before a BodySculp treatment. Treatment Seat the patient in a comfortable, reclined position and mark the treatment areas on their body. Begin with a 4-minute warming phase. Set the applicator energy to 1-W/cm2 for 2-minutes. After 2-minutes increase the applicator energy to 1.1-W/ cm2 After an additional 2-minutes, increase the applicator energy to 1.3-W/ cm2 During treatment, the BodySculp belt and applicators are wrapped around the treatment area. The applicators deliver a 1060-nanometer of light that will reach a temperature between 107.6 and 116.6°F. This temperature will kill fat cells underneath the skin while leaving other tissues unharmed. The BodySculp device alternates between delivering a cooling effect and the laser heat. Each treatment takes about 25 minutes. Over the next few weeks after the procedure, the patient’s lymphatic system naturally flushes out the eliminated fat cells. Additional treatments should be scheduled 4-6 weeks apart. BodySculp risks and side effects The heating phases during treatment may cause some minor discomfort. However, a numbing agent or anesthesia can be used but is not necessary. After treatment, the patient may experience some soreness and stiffness. While rare, the patient may also experience bruising in the treated areas. The patient may want to massage the firm areas during the weeks after the procedure. BodySculp results and recovery BodySculp takes 25 minutes and is non-invasive with little to no recovery time. This means that the patient could feasibly have a treatment done on their lunch break and return to regular work immediately. As your patient’s body metabolizes the eliminated fat cells, fat reduction may be noticeable in as few as three weeks after one treatment. On average, one session should result in a 24 percent reduction of fat in the treated area. Full results are normally seen 12 weeks after the last treatment. Because the cells eliminated during the procedure are destroyed with the laser, these cells will not regenerate. Desired fat reduction should be maintained through healthy diet and exercise. The BodySculp delivers laser energy to heat the deep layer of fat. The heat that is created damages the fat cells. The damaged fat cells are then eliminated by the body through your lymphatic system. During the laser delivery, the applicators cool the skin throughout the entire treatment. When the treatment begins, it will feel warm, and over time the heat sensation will increase to short periods of intense deep heat. You may also experience some cramping, tingling, prickling or squeezing sensations deep in the fat layer. These sensations are normal and expected. These sensations indicate that the laser is effectively targeting and damaging the fat layer. • I consent to wear protective eyewear. • The treated areas should be massaged two (2) times a day for five to ten (5-10) minutes. There are no lifestyle restrictions following your BodySculp 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. You may use ice packs or Tylenol according to package instructions to help ease tenderness. • 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 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. I have been informed that firmness, hardness, nodules, redness, tenderness, swelling, pain, and bruising, are the most common side effects. These side effects will usually resolve on their own. Other less common side effects which can occur are itching, skin contour irregularities, dimpling, hyperpigmentation/hypopigmentation, asymmetry, necrosis, changes in skin laxity, numbness, blister or burn. Rare occurrences of fainting or dizziness have been noted during and/or after the treatment. I confirm that I have not had sun exposure within the last 7 days. 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 ____________________________________ from any and all liability, damages, cost and expenses arising from or out of the use BodySculp Laser 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 the above information understood, I am choosing to be treated with the BodySculp laser System.

The following problems may occur with any Laser Treatment

  1. There is a risk of scarring.
  2. Short term effects may include reddening, mild burning, temporary bruising or blistering. These coniferous usually reside within 1-3 months, but permanent color change is a rare risk. Avoiding sun exposure before and after the treatment reduces the risk of color change.
  3. Infection: Although infection following treatment is unusual, bacterial, fungal and viral infections can occur. Should any type of skin infection occur, additional treatments or medical antibiotics may be necessary.
  4. Bleeding: Pinpoint bleeding is rare but can occur following treatment procedures. Should bleeding occur, additional treatment may be necessary.
  5. Compliance with the aftercare guidelines is crucial for healing.

I have read, Initialed, and acknowledge these requirements, of my procedure to better assist with treatment adversities that can occur if protocol is not taken seriously. I know that this is an elective service and my questions regarding services have been answered satisfactorily. I understand this procedure and accept all risks and will notify TNP of any changes that could put my treatment at risk, I hereby release The Natural Place, Dr. Copeland, Buford & Bridget Hahn and staff from all liabilities associated with the Indicated procedure.

Signature Date*
This field is for validation purposes and should be left unchanged.