E-LUX Radio-Frequency

Consent Form

Personal Information

Please provide your details

Print Full Name *

Date of Birth *

Phone *

E-mail Address *

Consent Declaration

I understand that I will be undergoing Radio Frequency treatment and certify that I:

I am not pregnant or nursing

I Am over 18 years of age

I do not have a pacemaker, internal defibrillator, or metal implants in the treatment area

I do not have current or a history of cancer, especially skin cancer, or pre-malignant moles in the area of treatment

I do not have an impaired immune system due to immunosuppressive diseases such as AIDS and HIV, or use of immunosuppressive medications

I do not have any severe concurrent conditions such as cardiac disorders

I do not have a history of diseases stimulated by heat, such as recurrent Herpes Simplex in the treatment area. If so, I agree to use prophylactic antiviral therapy.

I do not have any active condition in the treatment area, such as sores, psoriasis, eczema and rash as well as excessively/freshly tanned skin

I do not have a history of skin disorders such as keloid scarring, abnormal wound healing, as well as very dry and fragile skin

I have not had any surgical, invasive, ablative procedure in the treatment area before treatment

I do not have any medical condition that might impair skin healing

I do not have any permanent implant in the treated area such as metal plates and screws, silicone implants or an injected chemical substance

I do not have any poorly controlled endocrine disorders, such as diabetes

I have not used Isotretinoin (Accutane®) within 6 months prior to treatment

I understand that this treatment is not guaranteed to achieve the results that I want and there is no way to predict the response that I will get.

I understand that it will take 6-12 months to see maximal benefits and that any benefits will be reduced or eliminated with weight fluctuations, and normal aging.

Signatures

Confirm your consent

Therapist Name *

Client Name *

Date *

By submitting this form, I confirm that I have read and understood all the information above, and I consent to the Radio Frequency treatment.