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COSMED LASER SPA 

VIORA REACTION INFORMED CONSENT (BODY / FACE and NECK)

I do understand the cancellations and rescheduling policy and agree to pay the appropriate fees if I do not cancel or reschedule within 24 hours of my appointment date and time.

I do understand that taxes and gratuities are not included in any service I purchased. It is common practice to tip 15-20 % of the original service price. Please feel free to extend a gratuity as a result of your experience. Gratuities are accepted in the form of cash or credit card.

There will be improvement in cellulite appearance, but not complete elimination.

There will be improvement in thigh’s circumference, however, the response is individual. 

The degree of response to the Reaction treatment, and the number of treatment sessions required will vary among patients and will depend on the clinical and physiological condition at the start of the treatment regimen.

Some patients respond more than others. 

Treatment duration with VIORA REACTION will last 20-30 mins, depending on the number of treated areas as well as the size of treated areas. 


 

The treatment results are temporary and one maintenance treatment session every 3-6 months.

A healthy lifestyle (diet and exercise) may help to obtain better results, but is not essential. 

Superficial acne scarring and enlarged pores may show some improvement by building new collagen in the dermal area. 

A healthy lifistyle (diet and exersices) may help to obtain better result, but is not essential, however, weight gain have a negative effect on the result.


 

Side Effects and Complications Either for Body or Face / Neck:

  1. Excessive skin redness (erythema) and/or mild swelling, discomfort, hematoma, uriticaria.
  2. Allergic contact dermatitis to the acoustic contact gel, bruising.
  3. Changes in skin texture (crust, blister, burn)


 

I understand that there are NO GUARANTEES as Reaction treatment is not an exact science and results vary from person to person. 

I am hereby taking the responsibility of the treatment outcome.

I understand that occasionally there is no visible improvement and another treatment may be required.


 

 

 

First Client's Name

First Name*

Last Name*

Phone*
First Client's Age Acknowledgment*
First Client's Date of Birth*
I certify that I am 18 years of age or older
First Client's Information
What would you like to treat:*
I understand that i will be injected with one of the following*
Face / Neck
Body
What topical medications or creams are you currently using?
Retin-A

Others (Please list):

FOR OUR FEMALE CLIENTS:


Occupation
First Client's Signature*
Second Client's Name

First Name*

Last Name*
Second Client's Date of Birth*
Second Client's Information
What would you like to treat:*
I understand that i will be injected with one of the following*
Face / Neck
Body
What topical medications or creams are you currently using?
Retin-A

Others (Please list):

FOR OUR FEMALE CLIENTS:


Occupation
Third Client's Name

First Name*

Last Name*
Third Client's Date of Birth*
Third Client's Information
What would you like to treat:*
I understand that i will be injected with one of the following*
Face / Neck
Body
What topical medications or creams are you currently using?
Retin-A

Others (Please list):

FOR OUR FEMALE CLIENTS:


Occupation
Fourth Client's Name

First Name*

Last Name*
Fourth Client's Date of Birth*
Fourth Client's Information
What would you like to treat:*
I understand that i will be injected with one of the following*
Face / Neck
Body
What topical medications or creams are you currently using?
Retin-A

Others (Please list):

FOR OUR FEMALE CLIENTS:


Occupation
Fifth Client's Name

First Name*

Last Name*
Fifth Client's Date of Birth*
Fifth Client's Information
What would you like to treat:*
I understand that i will be injected with one of the following*
Face / Neck
Body
What topical medications or creams are you currently using?
Retin-A

Others (Please list):

FOR OUR FEMALE CLIENTS:


Occupation
Sixth Client's Name

First Name*

Last Name*
Sixth Client's Date of Birth*
Sixth Client's Information
What would you like to treat:*
I understand that i will be injected with one of the following*
Face / Neck
Body
What topical medications or creams are you currently using?
Retin-A

Others (Please list):

FOR OUR FEMALE CLIENTS:


Occupation
Seventh Client's Name

First Name*

Last Name*
Seventh Client's Date of Birth*
Seventh Client's Information
What would you like to treat:*
I understand that i will be injected with one of the following*
Face / Neck
Body
What topical medications or creams are you currently using?
Retin-A

Others (Please list):

FOR OUR FEMALE CLIENTS:


Occupation
Eighth Client's Name

First Name*

Last Name*
Eighth Client's Date of Birth*
Eighth Client's Information
What would you like to treat:*
I understand that i will be injected with one of the following*
Face / Neck
Body
What topical medications or creams are you currently using?
Retin-A

Others (Please list):

FOR OUR FEMALE CLIENTS:


Occupation
Ninth Client's Name

First Name*

Last Name*
Ninth Client's Date of Birth*
Ninth Client's Information
What would you like to treat:*
I understand that i will be injected with one of the following*
Face / Neck
Body
What topical medications or creams are you currently using?
Retin-A

Others (Please list):

FOR OUR FEMALE CLIENTS:


Occupation
Tenth Client's Name

First Name*

Last Name*
Tenth Client's Date of Birth*
Tenth Client's Information
What would you like to treat:*
I understand that i will be injected with one of the following*
Face / Neck
Body
What topical medications or creams are you currently using?
Retin-A

Others (Please list):

FOR OUR FEMALE CLIENTS:


Occupation
Client's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Age Acknowledgment*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information
What would you like to treat:*
I understand that i will be injected with one of the following*
Face / Neck
Body
What topical medications or creams are you currently using?
Retin-A

Others (Please list):

FOR OUR FEMALE CLIENTS:


Occupation
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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