HIFU Consent Form & Liability Waiver

• I Certify that I am over the age of 18

• I have voluntarily elected to receive high-frequency focused ultrasound (HIFU) after the nature and purpose of this treatment has been explained to me.

• I understand that the HIFU system delivers a low amount of focused ultrasound energy to the skin. The heat from the ultrasound stimulates new collagen to form.

• I understand that there can be discomfort during the treatment when the ultrasound energy is delivered

• I have discussed with my practitioner the options available to me to prioritize my comfort during the procedure.

• I understand that this non-invasive treatment is not intended to produce the same results as an invasive surgical process.

• I understand that immediately following the HIFU treatment, the skin may appear red for a few hours.

• I understand that it is not uncommon to experience slight swelling for a few days following the procedure or mild tingling and/or tenderness to the touch for days to weeks following the procedure.

• I understand that occasional temporary effects may include bruising or welts, which resolve in hours to days or numbness in a select area, which resolves in days to weeks.

• I understand that as with any medical procedure, there are possible risks associated with the treatment. There is a remote risk of a burn that may or may not lead to scarring (either of which will respond to medical care) or temporary nerve inflammation, which will resolve in a matter of days to weeks. Temporary local muscle weakness may result after treatment due to inflammation of a motor nerve. Temporary numbness may result after treatment due to inflammation of a sensory nerve.

• It has been explained to me that the results vary from patient to patient, and occasionally the collagen-building on the inside that helps counter the effects of gravity does not have a visible effect on the outside. I understand that results will unfold over the course of 3 to 6 months, and that some patients may benefit from having this treatment at this time and verify that none of the following conditions apply to me at this time:

• Cardiac Issues

• Cancer

• Infected, inflamed, or swollen skin

• Blood diseases

• Coagulation problems

• Metallic Implant (pacemaker)

• Pregnant/lactating

 have read and fully understand this agreement and all information detailed above. I understand the procedure and accept the risks. I agree I assume the risk and full responsibility for any and all injuries, losses, side effects, or damages that might occur to me while I am undergoing this procedure. I do/will not hold the technician or Bossy Glam Studio Inc responsible for any of my conditions that were present, but not disclosed at the time of this procedure, and any future procedure, which may be affected by the treatment performed today and or in the future.

I Authorize Bossy Glam Studio Inc to begin my HIFU treatment