Venus Bliss Medical History + Consent Form
During your consultation we will have reviewed with you the potential benefits, associated risks and alternatives of the Venus Bliss Laser. You were also provided with a booklet outlining this information. It is important that you read the information contained in this booklet again carefully and completely. By submitting this form, you are indicating that you have read and fully understood all the items this booklet discusses and do not have any remaining questions or concerns about the potential benefits, associated risks or alternatives of the Venus Bliss Laser.
The Venus Bliss Laser is a comprehensive, safe and effective platform system integrating laser technology to address issues with unwanted fat. The system integrates a 1064nm diode, which delivers laser energy to subcutaneous tissue layers for fat specific lipolysis. Automated “build” and “sustain” heating cycles to ensure comfortable temperature elevation and sustaining throughout the treatment exposure. By receiving Venus Bliss Laser treatments, you may benefit from fat tissue reduction in the treatment area. When discussing the potential benefits of the Venus Bliss with you, may have been shown you a variety of before and after images. It is important to remind you that these images were used as an educational tool to allow you to visualize the general range skin improvements that may be achieved with your proposed treatment; the before and after images are not meant to be guarantees of actual or exact outcome.
Every cosmetic procedure involves a very small degree of risk and, although exceedingly uncommon, it is important that you understand and accept the rare risks involved with the Venus Bliss Laser. An individual’s informed decision to undergo any cosmetic procedure is based upon a comparison of the risks against the potential benefits, alternatives and costs. Although the vast majority of Venus Bliss Laser patients never experience any of these complications, you should discuss each of them with epic MedSpa to ensure you fully understand the alternatives, risks, potential complications and average outcomes of the Venus Bliss Laser treatments
Blisters – in rare cases a blister may occur as a result of the treatment. In this instance, an after product may be recommended.
Slight tenderness in the treatment area lasting several weeks, in this instance, ice packs may be applied.
Swelling – edema, swelling of the skin, is common and will resolve in a few days. Edema may occur as early as immediately post treatment and as late as a few days post treatment. It is advised to seek a consultation and follow up appointment should you require medical attention or have concerns.
Redness in the treatment area which may last for several weeks.
Other side effects which may be observed, but are extremely rare include, but not limited to, skin contour irregularities, dimpling of skin, numbness, hypopigmentation/hyperpigmentation, asymmetry, itching, rash changes in skin laxity, and necrosis (tissue death).
Possible side effects related to the contact cooling in the treatment area include tingling, itching, decreased sensation, numbness, redness and tenderness.
There are many variable conditions, in addition to risks and potential complications listed above, that may influence the long-term result from the Venus Bliss Laser. Even though risks and complications can occur infrequently, the risks cited are particularly associated with the Venus Bliss Laser. Other complications and risks can occur but are even less common. Should complications occur, additional procedures or treatments may be necessary. The practice of aesthetics medicine is not an exact science. Although good results are expected, there is no guarantee or warranty, expressed or implied, as to the results that may be obtained. Infrequently, it is necessary to perform additional treatment to improve your results.
Female patients must not be pregnant nor wishing to become pregnant for the duration of the treatment program.
Most health insurance companies exclude coverage for cosmetic procedures such as the Venus Bliss Laser. Health related complications that may arise from such treatment may not be covered by all insurance plans. Please carefully review your health insurance subscriber-information pamphlet, if you have a private insurance carrier. For the avoidance of doubt, please be advised that the aforesaid is not intended to replace professional insurance advice. You are encouraged to seek further advice from insurance advisor at your jurisdiction. You will be responsible for all necessary payments. Additional costs may occur should complications develop from treatment. There are no refunds once a treatment has been performed.
What has been discussed with you are the material risks both common and uncommon that epic MedSpa feels a reasonable person would want to know, understand and consider in trying to decide if the proposed treatment of a condition is something they would like to proceed with. Informed-consent documents are not intended to define or serve as the standard of medical care. Standards of medical care are determined on the basis of all of the facts involved in an individual case and are subject to change as scientific knowledge and technology advance and as practice patterns evolve.
I have received the following information/informed consent for:Venus Bliss Laser Treatment
I hereby authorize epic MedSpa to perform the following Venus Bliss procedure.
I recognize that during the course of the procedure/treatment unforeseen conditions may necessitate different procedures than those above. I therefore authorize epic MedSpa staff to perform such other procedures that are in the exercise of their professional judgment necessary and desirable. The authority granted under this paragraph shall include all conditions that require treatment and are not known at the time the procedure is begun.
I acknowledge that no guarantee has been given by anyone as to the results that may be obtained.
I consent to the photographing or televising of the procedure(s) to be performed, including appropriate portions of my body, for medical, scientific or educational purposes, provided they do not reveal my identity. These photographs and videos may be used for medical meetings, advertising, or any promotional or public relations purposes.
I understand that the signature of the witness (if a non-physician) on this document indicates only that the signing of my name has been observed and not that the witness has necessarily provided information regarding the procedure.
IT HAS BEEN EXPLAINED TO ME BY EPIC MEDSPA STAFF IN A WAY THAT I UNDERSTAND: A) THE TREATMENT OR PROCEDURE TO BE UNDERTAKEN B) THERE MAY BE ALTERNATIVE PROCEDURES OR METHODS OF TREATMENT C) THERE ARE RISKS TO THE PROCEDURE/TREATMENT PROPOSED D) ANY QUESTIONS I MAY HAVE ASKED HAVE BEEN ANSWERED TO MY SATISFACTION, AND I AM SATISFIED WITH THE EXPLANATION.
BY SUBMITTING THIS FORM, I CONSENT TO THE PROCEDURE AND/OR TREATMENT AND THE ABOVE LISTED ITEMS.