SAFYRE RF / RADIOFREQUENCY CONSENT FORM
PLEASE READ THE INFORMATION BELOW BEFORE YOUR SAFYRE RADIOFREQUENCY TREATMENT
THEN COMPLETE THE FORM
I HEREBY DECLARE THAT:
For the present document I require and give my consent to the Operator @ Southend Laser and also his / her assistants execute in my own, the treatment known as SAFYRE RF / RADIOFEQUENCY
I understand the warnings and side effects, and I certify not to modify or omit my personal information or my medical history, as well as confirming that I do not suffer any contraindication.
SAFYRE is designed for body reshaping and facial rejuvenation treatments. SAFYRE uses RF technology to generate a radio frequency electromagnetic current acting on the body by causing a localized hyperemia. This increase of temperature inside the tissues activates the release of heat shock proteins, which protect collagen, avoiding denaturation and recovering the affected. Besides, there is an increase in the circulatory response in the treated area that facilitates the supply of oxygen and nutrients to the tissues, as well as an improvement in the removal of toxins. The main result is skin rejuvenation, cellular strengthening and increased tissue firmness.
Before undergoing the SAFYRE procedure, you should read and understand properly the potential adverse effects that may result from treatment:
- Redness on the treated area.
- High heat sensation in the treated area for 30 minutes after treatment.
Patients who should be excluded for the SAFYRE procedure are those with contraindications such as:
- Women IUD users.
- Metal implants.
- Reduced thermal sensitivity due to the lack of cutaneous sensitivity.
- Do not use creams with hot or cold effect
- Pregnant Women
- Lactation periods
- Thrombosis risk.
- Neoformations (cancer).
- Kidney Diseases
- Do not use menthol products, alcohol or products that accelerate cell regeneration (glycolic or fruit acids).
- Internal electrical and electronic implants or connected with the exterior, with batteries or radio controlled, such as: Pacemaker. Neurostimulators. Drug dispensers. Cochlear hearing implants.
- External monitoring.
- Internal bleeding processes in acute phase.
- Patients undergoing declotting treatment.
- In the first 48 hours of postoperative for certain pathologies.
- Metallic prostheses carriers.
- Patients with malignant neoplasm. People who are non-sensitive to temperature.
- Infectious processes in action.
- People who suffer uncompensated arthropathies.
I UNDERSTAND that the finality of this treatment is to improve my personal appearance having the possibility that some imperfection will persist and the result will be not the wished by me. I’m aware that medicine it’s not an exact science and nobody can guarantee to me the absolute perfection. I aware that the result could not be the expected by me and I recognize that nobody gave me such guarantee.
I HAVE BEEN INFORMED that number of necessary treatments to get the wished effect has been informed to me in an indicative way, being impossible to know in advance, the numbers of sessions which are necessary due to the different reaction of each patient.
I COMMIT myself to follow faithfully, at the best of my possibilities, the operator instructions before, during and after the treatment mentioned before. Being under my responsibility the compliance of the recommended prescriptions done by the Center.
I CERTIFY not to modify or omit my personal information or my medical history and clinic-surgical antecedents, specially referred to allergies, illness or personal risks.
I GIVE MY CONSENT, to take photographs on the treated zone of my body to be used for scientific, teaching or medical purposes. It being understood that its use does not constitute any violation of privacy or confidentiality, to which I am entitled.
I know that my data will be processed automatically, which authorize when they had been explained my rights under the current Official Data Protection Act (LOPD).
I have been informed, also, my right to refuse treatment or revoke this consent.
I was able to answer all my questions about all the above and I fully understand this consent in every one of its points and signed the document IN ALL PAGES AND DUPLICATE ratify and consent to treatment is obtained.