WP E-Signature by Approve Me - Sign Documents Using WordPress -

CONSENT FORM PELLEVÉ

As a patient, it is important for you to understand the expected results and risks of radiofrequency skin treatment with the Ellman lnternational Pellevé Wrinkle Reduction System. Please read this document carefully. Before signing, please ask your aesthetician about any aspect of this document, or the Pellevé procedure that you do not understand.

Pellevé Wrinkle Reduction System equipment may present a hazard to patients with implantable devices or pacemakers. 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 anywhere in the treatment area, you should not be treated with Pellevé.

Pellevé for wrinkle treatment uses the Surgitron Dual RF S5 equipment and is unstudied and unknown for pregnant patients, patients with autoimmune disease, diabetes, or herpes simplex.

Pellevé System
Ellman's Pellevé Wrinkle Reduction System has been cleared by the FDA for the non-ablative treatment of mild to moderate facial wrinkles and laxity on all skin types. AII patients are different and exact results of this cosmetic procedure and treatments cannot be predicted or guaranteed. Our studies indicate that greater than 85% of patients still have observable results six months or longer after treatment. For optimal results, a series of 4-6 initial treatments is recommended 3-4 weeks apart.

Treatment
Pellevé is a standalone treatment, which means it cannot be combined with any other procedure. No other procedures may be performed within the week of Pellevé, and no laser or injectables can be done 2 weeks before and after Pellevé.

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. AII jewelry, contact lenses, and makeup- including lotions, eyeliner, and eye shadow should be removed from the treatment area prior to treatment.

Treatment should not be performed on 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 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 aesthetician performing the treatment. Therefore no anesthetic (topical, local, oral, or systemic) should be used prior to or during the treatment. lnadequate or impaired feedback may lead to injury, burns, or excessive discomfort.

After Treatment

Studies indicate that the possible side effects of Pellevé 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 repeated application of sunscreen is imperative two to three weeks after treatment to minimize pigment changes.

After Treatment Studies indicate that the possible side effects of Pellevé 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 repeated application of sunscreen is imperative two to three weeks after treatment to minimize pigment changes.

Date:

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

Draw Signature
Type In Signature

Draw your signature with your mouse, tablet or smartphone Clear

I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

I agree that I am and I understand this is a legal representation of my signature

Adopt & Sign

Timestamp

Audit

May 14, 2020 12:28 pm MDT

CONSENT FORM PELLEVÉ Uploaded by Dermatology Partners Inc - ilan@ntmatter.com IP 181.166.195.138