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Consent Form

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TONE Informed Consent

I authorize Sei Tu Bella Aesthetics to preform the TONE treatment.
I understand that the device being used for muscle tone improvement of which I am consenting to be a patient receiving TONE treatment.
I understand that clinical results may vary depending on individual factors, including but not limited to medical history, skin type, patient compliance with preand post- treatment instructions, and individual response to treatment.
I understand that there is a possibility of short-term effects such as reddening, mild burning, pain, swelling, muscles spasm, and temporary discoloration of the skin, as well as the possibility of rare side effects such as treatment area
infection, scarring and permanent discoloration.

These effects have been fully explained to me _______ (patient’s initials).

I understand that treatment with this system involves a series of treatments and the fee structure has been fully explained to me _______ (patient’s initials).

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 taken.
I consent to the taking of photographs and authorize their anonymous use for the purposes 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 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 the mytreatments in the future as well.

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