PATRICIA BEARNSON, M.D

PHASE II SkinCare

Patient Consent

Velasmooth

Patient name _______________________________________________

Treatment sites _____________________________________________

I duly authorize _____________________________ to perform the VelaSmooth procedure and any other measures, which in their opinion may be necessary.

I understand that the VelaSmooth is a device used for improving the appearance of cellulite.  It may also be therapeutic for improving circulation and muscle aches in the treated areas.  I understand there is a possibility of short-term effects such as reddening, blistering, scabbing, temporary bruising and temporary discoloration of the skin, as well as rare side effects such as scarring and permanent discoloration.  These effects have been fully explained to me _______ (patient’s initials)

Clinical results may vary depending on individual factors, including medical history, skin type, patient compliance with pre/post treatment instructions, and individual response to treatment.

I understand that treatment by the VelaSmooth system involves a series of treatments and the fee structure has been fully explained to me _______ (patient’s initials)

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 cosmetic concern and that the decision to proceed is based solely on my expressed desire to do so.

I confirm that I am not pregnant at this time, and that I have not taken Accutane within the last 6 months.  I do not have a pacemaker or internal defibrillator.  I do not have a history of keloid scarring, systemic or local malignancies, and do not have poorly controlled diabetes.  I do not have history of lower extremity thrombus or blood clot formation, and am not photo allergic. I will inform the clinician of any changes to my medical history during the course of VelaSmooth treatment sessions.

I consent to the taking of photographs and authorize their anonymous use for the purposes of medical audit, education and promotion.

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.

Patient Signature__________________________________________

Date_________________________________

Witness______________________________