Morpheus V Informed Consent
I duly authorize Sei Tu Bella Aesthetics to perform the MORPHEUS8V treatment.
I understand that the MORPHEUS technology utilizes fractional radiofrequency (RF) to induce ablation, thus improving the appearance of the treated tissue, stimulates collagen generation and replenishment. It has been explained to me that although RF treatments has 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 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.
8. When using Morpheus8, there is a potential low-level stimulation of branches of the facial nerve, and involuntary contraction of the underlying muscle may occur. This is transient and is not harmful, as the Morpheus8 effect diminishes at the deeper level where parts of the nerve lie above the muscles. These effects have been fully explained to me. _______ (patient’s initials).
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 agree to waive, release, discharge, and covenant not to sue Invasix, Inc. d/b/a InMode (“InMode”) and its employees, agents, and representatives, from any liability, loss, cost, damage, expense, claim, or lawsuit whatsoever for any and all injury, loss, illness, harm, cost, expense, or damage related to the treatment, including any negligent acts or conduct by InMode and its agents, employees, and/or representatives (collectively, “Claims”). 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 take full liability and responsibility for any and all risks, undesired outcomes, or adverse events associated with the injections and will not hold the providers liable for any unfavorable outcome or adverse event. I release Sei Tu Bella Aesthetics LLC, owners, and medical staff from liability associated with the procedure. This consent form is freely and voluntarily executed and shall be binding upon my spouse, relatives, legal representatives, heirs, administrators, successors, and assigns. I relieve Heather Merlo, FNP-C, APRN, Medical Director Dr. Fernando Jara and Sei Tu Bella Aesthetics LLC, from all legal action pertaining to this treatment.
Patient Signature ____________________________ Date
Witness Signature ___________________________ Date