Thermage Consent

  • Date Format: YYYY dash MM dash DD
  • a). Glaucoma (only when applying eye shield inserts) b). Pregnancy or IVF procedure c). Skin conditions / irritated skin d). Phlebitis and blood-clotting e). Cancer or cancer treatment f). Heart disease, gastric ulcer, serious gastropathy, duodenal ulcer g). Active collagen or vascular disease h). Recent (less than 6 months) use of Isotretinoin (Roaccutane) i). Implantable pacemaker or automatic defibrillator/ cardioverter (AICD) or Cockle Ear Implant j). Large dental metallic prosthetic implants k). Multi systemic diseases (diabetes, hypertension, coronary artery disease, renal insufficiency etc.)
  • a). Heating sensation or pain to the treatment area b). Redness to the treatment area c). Superficial burns to the treatment area d). Temporarily dry skin to the treatment area e). On diet medication (you can recommence using medication after 1 month after last treatment) f). That I am menstruating on the day of the treatment (allowable but could result in sensitivity)
  • 7. I consent to photographs being taken to evaluate my treatment effectiveness. I consent to photographs being used for medical education & training, but not for public display or advertising.


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