The purpose of this procedure is to tighten sagging skin in the areas indicated above. The procedure may require more than one treatment and may produce some reduction in the appearance of sagging skin and/or wrinkles as well as lifting.

The total number of treatments and clinical results and may vary between individuals.

Most patients require a number of treatments over several months with gradual results occurring over this time. On occasion there are patients that do not respond to treatments and so the outcome cannot be guaranteed.

I was informed about the other alternative methods as well as their benefits and disadvantages.

No guarantee, warranty, or assurance has been made to me as to the results that may be obtained.

I am also aware that follow-up treatments may be necessary for desired results.

Alternative methods available such as fillers, botulinum toxin, dermabrasion, chemical peels etc. have been discussed and explained to me.

The following problems may occur with the procedure.

1. Short-term effects may include reddening, mild swelling, mild burning and temporary bruising. These conditions usually resolve within 1-3 weeks.
2. Rarely temporary numbness of the treated skin may be seen after treatment and will resolve with time (generally days to weeks).
3. Infection: Although infection following treatment is unusual; bacterial, fungal and viral infections can occur. Should any type of skin infection occur, additional treatments might be necessary.

Topical, local or general anesthesia may be required in few patients but HIFU is usually performed without ahesthsia and is quite tolerable.

I agree that any pictures taken of my treatment site may be used for publication or teaching purposes; however my name or identity will not be disclosed and complete confidentiality will be maintained.

By signing below, I acknowledge that I have read the adverse reactions above and I feel that I have been adequately informed of the risks of Hi Intensity Focused Ultrasound treatment.

Before each treatment, I will inform the doctor if I have taken any new medications since my last treatment.

I also agree to comply with the recommended aftercare instructions.

I hereby release My Laser Room and its designated staff from liability associated with the above procedure.

My questions regarding the procedure have been answered satisfactorily.