I hereby authorize Harmony Wellness Spa therapists under supervision to treat me with the Medilift device. I understand that Medilift works by using EF Electro-frequency energy to provide uniform deep tissue heating for the purpose of elevating tissue temperature for the treatment of selective medical conditions.

 

There is little or no downtime associated with this treatment. It is possible the result will be minimal or not help at all. I am aware that office policy is that there are no refunds or credit given for dissatisfaction or undesirable results. I am aware that office policy is that there are no refunds or credit given for dissatisfaction or undesirable results.

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The procedure may result in the following adverse experiences or risks:

• DISCOMFORT/PAIN Moderate discomfort during treatment is expected. Mild discomfort or slight tenderness in the treatment area may persist for a few hours following treatment, potentially extending to a few days.

• REDNESS/SWELLING/BRUISING Short term redness (hyperemia) is expected following treatment and typically persists for several hours. In addition, swelling (oedema) and/or bruising of the treated area may occur and typically resolve within 24 hours to a few days.

• BRUISING/PETECHIAE OUTSIDE THE TREATMENT AREA May occur under the area where the decal is applied and can occur in the process of removing the decal from patient’s skin.

• LUMPS Firm edemic areas may develop in the treated area 24 to 72 hours following treatment, and typically resolve without intervention over several weeks. If lumps do develop, they are typically tender to touch.

• INFECTION Infection is a possibility whenever the skin surface is disrupted, although proper wound care should prevent this. If signs of infection develop, such as pain, heat, or surrounding redness, please call our spa. It is IMPORTANT that you follow all post-treatment instructions provided by your healthcare staff.

• SCARRING Scarring is a rare occurrence, but it is a possibility if the skin surface is disrupted. To minimize the chances of scarring, it is IMPORTANT that you follow all post-treatment instructions provided by your healthcare staff.

• SKIN COLOR CHANGES If the skin surface is disrupted, there is a possibility that the area may become either lighter (hypopigmentation) or darker (hyperpigmentation) in colour compared to the surrounding skin. This is usually temporary, but, on a rare occasion, it may be permanent.

• NUMBNESS Temporary numbness may occur, but is rare.

I acknowledge the following points have been discussed with me:

• Potential benefits of the proposed procedure, including the possibility that the procedure may not work for me

• Alternative treatments such as surgery

• Reasonably anticipated health consequences if the procedure is not performed.

• Possible complications/risks involved with the proposed procedure and subsequent healing period

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For women of childbearing age: By Confirming below I confirm that I am not pregnant and do not intend to become pregnant anytime during the course of treatment. Furthermore, I agree to keep staff informed should I become pregnant during the course of treatment.

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Photographic documentation will be taken. I authorize the use of my photographs for teaching purposes.

ACKNOWLEDGMENT. Please Let us know if you do not wish for your photos to be used.

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BY MY clicking CONSENT and completing the consent form , I ACKNOWLEDGE THAT I HAVE READ AND FULLY UNDERSTAND THE CONTENTS OF THIS INFORMED CONSENT FOR THIS TREATMENT, AND THAT I HAVE HAD ALL MY QUESTIONS ANSWERED TO MY SATISFACTION BY MY HEALTHCARE TEAM.

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