Consent For EndyMed

Name *

First

Last

Email *

Last 4 Digits Of IC Number

Are you sensitive or allergic to anaesthesia cream?

Yes
No

Patient Safety

I hereby declare that I have received detailed information regarding the use of the EndyMed system that uses radiofrequency (RF) energy for skin tightening
Treatment that uses RF energy for skin tightening results in deep heating of the skin in the treatment area. The treatment should not cause any pain, and usually has no side effects. Use of the system may cause temporary swelling and redness of the ski
In rare cases, a burn may occur at the treatment site. In this case, the treating therapist will immediately treat the area and will receive instructions on the course of treatment
I do not have implanted pacemakers ,arrhythmias or any other severe known heart disorder
I am not pregnant or lactating subjects
I do not have active or recent cancer of any kind
I am not using blood thinning medications, non-steroidal anti-inflammatory drugs (NSAIDS, e.g., ibuprofen containing agents) one week before and after treatment or any medication that would affect the characteristic of the skin (medical or hormonal), such as Isotretinoin (Accutane) within the past two months.
I do not have any history of diseases stimulated by heat, such as recurrent Herpes Simplex in the treatment area, may be treated only following a prophylactic regime.
I do not have any history of hip replacement, hip or femur surgery, or other metallic device in the treatment zone.
I do not have any form of suspicious lesion on the treatment area such as sores, psoriasis, eczema, and rash.
I hereby declare that I have read the above and understandthe implications andthat my consent is providedof my own free will. I have received a copy of thisconsent form, signed and dated

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