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RADIO FREQUENCY for Face or BODY
TREATMENT CONSENT FORM
Name: ______________________________________________________ Date: ________________________
DOB: __________ Phone: ___________________ Email: ___________________________________________
Area of treatment: (Circle one) Face - Body
Medical history: (please mark any that apply to you)
_____ Pregnancy or nursing (current only). _____ Areas of sensory impairment such as in cases of nerve
_____ Pacemaker or internal defibrillator, implanted neuro- lesions and neuropathies.
stimulators or another internal electric device.
_____ Current or history of, cancer - especially skin cancer, or _____ Any active condition in the treatment area, such as
pre-malignant moles in treatment area. sores, psoriasis, dermatitis, eczema and rash as well as
_____ Diabetes and Impaired immune system due to excessively/freshly tanned skin.
immunosuppressive diseases such as AIDS and HIV.
_____ Immune suppressive medications.
If getting the Face treated:
_____ Medications such as blood thinners. _____ Dental implants, braces, caps, metal fillings (amalgams,
_____ Severe concurrent conditions such as cardiac disorders gold)
or epilepsy. _____ Botox or filler in treatment area.
_____ Condition which could be adversely affected by heat. _____ Active weeping acne.
_____ A history of diseases stimulated by heat, such as _____ Continuous use of Retin A, retinol or any other Vitamin
recurrent Herpes Simplex in the treatment area. A derivatives.
_____ Herpes (active).
_____ Chemical sensitivities such as reactions to cosmetic
products or perfumes. If known, please list specific offending
ingredients: If getting the BODY treated:
_______________, ___________________, _____ Heavy menses/bleeding.
__________________ . _____ Metal implants or other implants in the treatment
_____ History of skin disorders such as keloid scarring, area- i.e. IUD, screws, plates.
abnormal wound healing, as well as very dry and fragile skin.
_____ Varicose veins in the treatment area.
_____ Any surgical, invasive, ablative procedure in the
treatment area before complete healing.
_____ Any medical condition that might impair skin healing
If you answered YES to any of the above, please explain: ______________________________________________________________
___________________________________________________________________________________________________________
Please list any medications you are currently taking:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Radio Frequency Treatment Client Name: _____________________________________ Client Initials ___________
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Disqualifying Conditions for Multipolar Radio Frequency Treatments
Check off in not applicable
NO: _____ A burn or care after such a burn
_____ Implants: heart pace-maker, braces, cochlear implants
_____ Coagulation dysfunction or bleeding disorders _____ Active cancer
_____ Organ transplants _____ Botox or filler in treatment area
_____ Pregnancy _____ Severe cardiovascular disease, circulation
_____Acute hernia, discopathy, spondylolysis _____ Accutane and retinol
_____ Lactation _____ Suppuration of soft tissues
_____Migraines or Epilepsy _____ Severe active arthritis
_____ Tuberculosis _____ Active gout Kidney stones
_____Malignant Tumors _____ Any active condition in the treatment area, such as
_____ Not feeling thermal changes troubles (thrombus arterial sclerosis, etc.) Herpes, sores,
_____Acute infections or inflammations psoriasis, dermatitis, eczema and rash
Please initial:
_____ I understand that taking the treatment course is my choice and that I am free to withdraw at any
time, without giving any reason.
_____ I was told about the possible side effects of the treatment including: skin redness (erythema) and warmth.
_____ Although these effects are rare and expected to be temporary, any adverse reaction should be reported
immediately.
_____ I understand that not everyone is a candidate for this treatment and results may vary.
_____ I confirm that I have read and understood the above information and will undergo the treatment out of my own free will.
_____ 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 a cosmetic concern and that the decision to proceed is based solely on my expressed desire to do so.
_____ I believe I have adequate knowledge upon which to base an informed consent.
_____ FINANCIAL: I understand that all payments are due at time of service. To receive package prices, payment must be made for
the entire package prior to service.
_____ CANCELLATION/Rescheduling Policy: Please be aware that all cancellations require a minimum of 24hrs notice. Failure to do
so will result in that treatment being deducted from your course without a refund. It is important to be aware that this may have
a negative effect on your overall results. Any changes to the initial treatment dates will be subject to availability.
_____ Due to the demand for treatments, we schedule all appointments following the initial consultation.
_____ I authorize before, during and after the procedure(s) the taking of photographs to be part of my patient
profile.
_____ I understand that it is my personal responsibility to inform the clinician of any changes to my medical history during the
course of Radio Frequency treatment sessions and I confirm that should this occur I shall advise the clinician of any changes 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 ___________________________________ confirm that all information provided above is correct to the best of my knowledge.
Client Signature: ________________________________________________________ Date: ______________________
Licensed Esthetician Signature: _____________________________________________ Date: _____________________
Radio Frequency Treatment Client Name: _____________________________________ Client Initials ___________
