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Consent Form

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Consent for VTONE

Patient name: ______________________________Treatment Sites: vaginal canal

I duly authorize Sei Tu Bella Aesthetics to perform the VTONE treatment.
I understand that the VTONE is an EMS (Electrical Muscle Stimulation) device used for intra vaginal treatment providing electrical stimulation and neuromuscular re education for the purpose of rehabilitation of weak pelvic floor muscles for the treatment of stress, urge, and mixed urinary incontinence in women. It has been explained to me that although EMS treatments have been very
effective there is no guarantee that I will benefit from this treatment. I understand the most common side effects and complications from this treatment are the following:

1. Pain: you may experience pain during or after the procedure. If you feel significant discomfort after the treatment, you may use over-the-counter pain medications after the procedure.

2. Swelling: there may be swelling in the treatment areas after the treatment which can last up to one week in duration.

3. Skin irritation and burns: you may experience a burn that can be mild, moderate, or severe to different degrees in the treatment area. Minor burns generally, heal without difficulty but more severe burns, though the rate can lead to scarring and sensory or pigmentary changes.

4. Scarring: the risk of this complication is minimal but it can occur whenever the surface of the skin is disrupted. Strict adherence to all post-operative instructions will minimize the possibility of this occurring.

5. Allergic reactions: it is possible to experience an allergic reaction to an anesthetic, topical cream or oral medication.

6. Herpes Eruption: it is possible, even with antiviral prophylaxis, to experience a herpes eruption if you are an HSV carrier. Inform your doctor immediately if you experience pain, skin eruptions or blistering post-treatment so that the proper treatment can be initiated.

7. Infection: this treatment has the potential to cause skin damage, so infection is possible. Infection is unlikely, but can be life-threatening if it does occur and is left untreated; signs and symptoms of infection are redness, fever, pain, pus, and swelling. Should an infection occur, you should contact your doctor for immediate evaluation and treatment. It is important that you tell your doctor if you experience any of these side effects.

I understand that clinical results may vary depending on individual factors, including but limited to medical history, skin type, patient compliance with pre/ post-treatment instructions, and individual response to treatment. I certify that I have been fully informed of the nature and purpose of the procedure, expected outcomes, and possible complications, and I understand that no guarantee can be given as to the final result obtained. I am fully aware that my condition is of cosmetic concern and that the decision to proceed is based solely on my expressed desire to do so.

I confirm that I have informed the staff regarding any current or past medical condition, disease, or medication that was taken. I confirm that I have had an up-to-date normal PAP test and that I have communicated these results.

I consent to the taking of photographs and authorize their anonymous use for the purpose of medical audit, education, and promotion.
I certify that I have been given the opportunity to ask questions and that I have read and fully understand the contents of this consent form.

I understand that the treatment may involve risks of complication or injury from both known and unknown causes, and I freely assume those risks. Prior to receiving treatment, I have been candid in revealing any condition that may have a bearing on this procedure.

I consent and authorize Sei Tu Bella Aesthetics, LLC, and it’s affiliates to perform the procedure listed on me. I certify that I have read this entire informed consent and I understand and agree to the information provided in the form. My questions regarding the procedure have been answered satisfactorily. I hereby release Heather Merlo, APRN, FNP-C, Medical Director Dr. Fernando Jara, Sei Tu Bella Aesthetics LLC from all liabilities associated with this procedure. This consent is valid for all of my treatments in the future as well.

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