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Radio Frequency Microneedle Informed Consent

 

This is an informed consent document, which has been prepared to help inform you about your Radio Frequency Microneedle procedure, the risks associated with this procedure, and alternative treatments. It is important that you read this information carefully and completely. After reviewing, please sign the consent authorizing the procedure to be performed.

During Radio Frequency Treatment:

·      You will feel multiple small needle injections and a slight stinging sensation, which will last about 3-5 seconds

·     You may feel a slight burning sensation lasting several minutes, but will cease

Before signing this document, please ask your physician, or the treating professional providing the service, about any aspect of this document, or the procedure, that you do not understand. 

Radio Frequency equipment may present a hazard to patients with implantable devices or pacemakers. To my best knowledge I do not have any of these devices and am qualified by medical personnel to being treated with radio frequency equipment.


I understand since ongoing feedback by a patient during a procedure is required, if I have nerve sensitivity to heat anywhere in the treatment area, or can not continue, I will not be treated with the Radio Frequency; however I agree to covering the cost of $150 for disposables used in my treatment, even if I elect to not complete it.


I understand Radio Frequency System equipment is unstudied and unknown for pregnant patients, patients with autoimmune disease, diabetes, or herpes simplex and as such, should be avoided by those particular patients. 


I understand Radio Frequency Microneedle has been cleared by the FDA for treatment of skin tightening on skin photoypes I-IV. All patients are different and exact results of this cosmetic procedure and treatments cannot be predicted or guaranteed.


 

During Treatment

Although very rare, during your 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. 

Slight discomfort may be experienced while undergoing treatment. Typically the discomfort is mild and temporary during the procedure and localized within the treatment area. During the treatment you should feel warmth and very tolerable heat, which will allow you to provide ongoing feedback to the individual performing the treatment. Additionally, if you have nerve insensitivity to heat anywhere in the treatment area, you should not be treated. Inadequate or impaired feedback may lead to burns or injury. You should provide ongoing feedback to the individual performing the treatment to avoid excessive discomfort, as the same is not necessary to bring about results by way of the Radio Frequency treatment.

 

After Treatment

Studies indicate the possible side effects of Radio Frequency are usually treatment-site related and can include mild discomfort during the procedure (localized within the treatment area). Again, although rare, mild swelling and redness may occur which typically resides and goes away within 2 to 24 hours.

Diligent protection from sun exposure and application of sunscreen for two to three weeks after treatment will minimize pigmentation changes.

A regimen to moisturize and soothe skin for one week post-treatment is recommended.

There is the possibility that additional risk factors of radiofrequency skin treatments may be discovered. The results of performing Radio Frequency 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 there are other treatment options such as microdermabrasion, 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 the physician or treating professional has answered all of my questions. 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 Radio Frequency Microneedle System.

STATE  MEDICAL SERVICES CONTRACT  All Medical treatments are performed by Edmund Fisher MD and Noam Rosines MD Inc. Medical Group, dba Luz Lounge. A signed copy of this document is to be emailed/given to the client upon request. Original is to be filed in Client’s medical records. Arbitration Agreement CD0501Y8v2 ARTICLE I: ARBITRATION Article 1.1: Agreement To Arbitrate: It is understood that any dispute as to medical malpractice by Client, including any party that would have standing to assert a claim on behalf of or in connection with services provided to Client, that is as to whether medical services rendered under this contract were unnecessary, unauthorized or lacking informed consent or were improperly, negligently, or incompetently rendered, will be determined by submission to arbitration as provided by State law, and not by a lawsuit or resort to court process except as State law provides for judicial review of arbitration proceedings. For purposes of this agreement, “Dispute” means any claim or controversy of whatever kind or nature including (without limitation) any claim or controversy regarding the formation, validity, interpretation and/or enforce ability of this agreement to arbitrate and any claim or controversy by the Client asserting loss of consortium, wrongful death, emotional distress or punitive damages. Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration.  Article 1.2: Procedure For Initiating Arbitration: Either party to this agreement may initiate Arbitration by submitting a Demand for Arbitration in writing to the other. The Demand shall contain a plain and simple statement of the nature of the Dispute and the remedy demanded. There shall be one Arbitrator who shall be a retired Judge of a court of record. The Arbitrator shall be selected by agreement of the parties on or before 30-calendar days of the date that the Demand for arbitration is deposited for delivery with a common carrier (as determined by a postmark or other equivalent writing imprinted by the common carrier). If the parties have not agreed to a selection of the Arbitrator, than either party may petition the appropriate Superior Court to appoint the Arbitrator and, consistent with CCP § 1281.6, the Superior Court shall appoint the Arbitrator, who shall have the qualifications stated in this paragraph.  Article 1.3: Law Governing Arbitration; Arbitrator’s Award And Enforcement. Without reference to its choice of law rules, the Arbitrator shall apply the substantive law. The Arbitrator shall render his or her award in writing and the award shall separately state the Arbitrator’s findings of fact and conclusions of law. The Arbitrator’s award shall be binding on the parties to the arbitration and judgment on the award may be entered by a court of competent jurisdiction. Judicial proceedings to confirm, amend, or vacate the arbitration award shall also take place. To the extent permitted by law, venue for such proceedings shall be in the county (or the federal judicial district) where the services were rendered. Unless the Arbitrator shall determine otherwise, the Arbitration shall take place in the county where the services were rendered. The Arbitrator shall have the authority to hear any claim and award any remedy that could otherwise be heard or rendered by the Superior Court or a federal district court. Discovery shall proceed in accordance with State Code of Civil Procedure, §§ 1283.1, 1282.05, and, in addition, any party, may, of right, bring a motion for summary judgment or adjudication in accordance with CCP § 437c. The parties to this agreement agree to arbitrate in one proceeding all claims arising out of the same or a related incident, transaction or occurrence. Article 1.4: Small Claims Court: Notwithstanding the foregoing any party to this agreement may initiate and prosecute in the small claims division of the Superior Court any claim at law demanding an amount equal to or less than the jurisdictional limit of the small claims division. Notwithstanding applicable law, no judgment in an action initiated in the small claims division may be entered for an amount in excess of the jurisdictional limit of the small claims division.  Article 1.5: Severability: If any provision of this arbitration agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provisions. NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY MUTUAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO JURY OR COURT TRIAL.




First Participant's Name

First Name*

Last Name*
First Participant's Age Acknowledgment*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Parent or Guardian's Email Address

Email*

Confirm Email*
Medical Questions
I don't have a Pace Maker*
No
Yes
Numbness in the area prior to treatment*
No
Yes
Are you Pregnant/Nursing?*
No
Yes
Issues with keloids, healing or bleeding.*
No
Yes
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*
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 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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