"*" indicates required fields

Patient Information

Patient Name*

THERMISMOOTH® Face Non-invasive Skin Tightening and Smooth Procedure Consent Form

Pre-NON-LASER TX’s – No Lotions on area to be treated, no recent sun exposure and or tanning creams of any kind, back Of antibiotics 3 days prior, back off retinaL and harsh chemicals.

Thermismooth® (2 weeks) is temperature-controlled radio frequency that heats the dermis to promote immediate contraction and stimulation of collagen, collagen remodeling and elasticity, and long-ten production of new collagen.

I, as a patient, it is important for you to understand the expected results and risks of radio frequency skin treatment with the ThemiRF System. Please read this document carefully. Before signing this document, please ask your physician, or the consultant providing the Thermismooth® treatment, about any aspect of this document, or the Thermismooth® procedure, that you de not understand.

The ThemiRF System equipment may present a hazard to patients with implantable devices, such as but not limited to pacemakers, imbedded defibrillators, and Cochlear ear implant. Please consult qualified medical personnel prior to being treated with radiofrequency equipment.

Since ongoing feedback by a patient during a procedure is required, if you have nerve insensitivity to heat anywhere in the treatment area, you should not be treated with the the ThermiRF System.

The Thermismooth® treatment use the ThermiRF equipment and unknown for pregnant patients, patients with autoimmune disease, diabetes, and herpes simplex.

During Treatment

You may feel an electric shock similar to a static discharge in a dry environment when the electrode makes contact or is removed from the skin. A common comparison is the static shock you might feel when touching something after dragging your feet across carpeting. Beard stubble should be thoroughly removed prior to treatment as remaining stubble may accentuate shocks. If the eyelids are to be treated directly, please have plastic, nonconductive eye shields covering your eyes.

All jewelry and makeup, including lotions, eyeliner and eye shadow should be removed from the treatment area prior to treatment.

Cut, wounded or infected skin should not be treated as this could promote infection and injury.

Slight discomfort may be experienced while undergoing treatment. Typically, the discomfort is mild and and temporary during the procedure and localized within the treatment area. During the treatment you should feel warmth and heat and provide ongoing feedback to the individual performing the treatment. Therefore, no anesthetic (local, oral or systemic) should be used prior to or during the treatment. Additionally, if you have nerve insensitivity to heat anything in the treatment area, you should not be treated. Inadequate or impaired feedback may lead to burns or injury. Ongoing feedback should be provided by you to the individual performing the treatment to avoid excessive discomfort.

Our face is the introduction to the world. Sagging skin around the eyes makes us looks tired, while droopy skin around the mid and lower face and neck region adds years. The development of jowls results in an ill-defined jawline, which becomes. There are major structural component in our skin, when deficient, results in droopy, sagging skin in our face – Collagen. Collagen is the substance which gives our skin strength and structure and plays a role in the replacement of dead skin cells. As the time passes and the effects of time, sun damage, pollution, poor lifestyle, less collagen is produced, resulting in sagging and drooping contours. Over the years, patients have turned to over-the-counter treatments and noninvasive therapies to help restore their skin, but without getting the desired skin tightening results. This until now…Thermismooth® Face, a revolutionary skin tightening treatment, now individuals have access to ground breaking RF technology with exceptional results. Thermismooth® Face is a topical RF procedure which is performed using a specially-designed thermistor-regulated hand piece, which delivers precise heating of the skin’s surface though a series of gentle treatments over 2 weeks. Patients often say it feels like receiving a warm massage. As the hand piece is gently moved across the skin, it heats the skin’s surface using dermal heating. ThermiSmooth Face is ideal on the face for problem areas around the forehead, eyes, mouth, cheeks, and neck. Common Questions: Who is a candidate for Thermismooth® Face? Thermismooth® Face is for both men and women with loose skin on their cheeks, neck, forehead, mouth and around the eyes. How many Thermismooth® Face treatments are required? Between 2 to 6 treatments are recommended, with 1 to 2 weeks gap between each treatment. Thermismooth® Face treatments are repeated until the desired result has been achieved, with the idea that the results keep improving with the following weeks and months. Every patient is unique; thus, it is impossible to say exactly how many treatment area. Once set to a specific temperature, the hand piece is moved in a circular fashion over the skin’s surface, gently heating the skin and adjusting the temperature based on the skin’s feedback. Though full results won’t occur until weeks after the treatment has been performed, patients can expect to see some results immediately after their first Thermismooth® Face treatment, with the results continuously improving. Is there any preparation needed? None.

How much discomfort will there be? The procedure is very comfortable, and to ensure comfort, topical anesthesia may be used. How much downtime after the treatment? Immediate. No downtime. You can go back to work, or enjoy a dinner with friends the same evening.

What to expect:

  • Collagen is like the reinforcing iron mesh in concrete. As we age, this mesh reinforcing the structure of our skin loses its strength.
  • Duration: 10-20 minute treatments spaced 1-2 weeks apart. You would require 2 to 6 sessions.
  • Comfort: Thermismooth® Face treatments are completely painless with topical anesthesia.
  • Downtime: None! You can resume normal activity the same day

Heating the skin can change collagen by:

  • Immediately contracting the molecule
  • Immediately remodeling or “reorganizing” the collagen molecules
  • Stimulating fibroblasts (the cells that build the collagen “mesh”) to create new collagen, giving you refreshed collagen immediately, and new collagen over time

Thermismooth® Face is Precise and Safe with the Following Advantages:

  • A gentle therapy
  • Non-invasive procedure
  • With no downtime
  • Only entailing a series of 3-6 treatments
  • Results keep on improving between treatments and even after the treatment sessions are over.

After Treatment

Possible side effects of the Thermismooth treatment are usually treatment-Site related and include mild discomfort during the procedure localized within the treatment area. Mild swelling and redness may’ occur which typically goes away within 2 to 24 hours.

Diligent protection from sun exposure and application of sunscreen after treatment will minimize pigmentation changes.

A regimen to moisture and soothe slid for one-week post-treatment is recommended.

Thermismooth Treatment Consent Non-Invasive Treatment for Skin Laxity, Wrinkle Improvement and Smoothing

There is the possibility that additional risk factors of radiofrequency skin treatments may be discovered. The results of performing ThermiSmooth treatments in combination with other treatments is unstudied and unknown. It has been explained to me that this is a cosmetic procedure and not covered by insurance. It has been explained to me that more than one treatment may be recommended to achieve the best results and that there are other treatment options such as chemical peels, filler injections, or no treatment at all. As mentioned before, there is no guarantee of results and no refund of payments for the procedure will be made. My signature below signifies that all of my questions have been answered by the physician or consultant. I understand the risks, complications, expected results, and expense of the treatments. I have read and understand this document and give my consent to receive treatment with the ThermiRF radio frequency system.

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, Dr. 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.