RF Microneedling Consent Form

I certify that the above statements are true and correct and I completely understand the implications of the treatment that I will be receiving, including the listed side effects. At no time have I been misled or badly informed by MADA Clinic and Spa. Any falsifications of information submitted by myself could be detrimental to my health and success of my treatment, and the company will not be held liable. I have been advised that I may experience possible discomfort during the treatment.*

I hereby authorise and direct them to administer the prescribed process and perform such procedures as may be deemed necessary or advisable. My signature below constitutes my acknowledgment that I have read, understood and fully agree to the statements above. I give consent to the proposed treatment process that has been satisfactorily explained to me and I have all the information I desire.*

I hereby give my consent and authorisation voluntarily and release the establishment and its agents of any claims that I have or may have in the future in connection with the described treatment.*

I hereby authorise MADA Clinic and Spa to treat me using the 3D Dermaforce. The limitations of treatment and expected treatment outcome has been explained to me and I also understand that a course of treatments are necessary with regular maintenance treatments in the future to obtain optimal results.*

The clinic above has informed me about alternative treatment possibilities and I understand that other forms of treatment or no treatment at all, are choices that I have.*

I agree to follow the clinic instructions regarding avoiding sun exposure during my treatment time with them and understand that not heeding these instructions may result in delay in my treatment programme.*

I agree to follow the post treatment recommendations advised by the clinic above in order to ensure the best possible results. I understand that excessive heat should be avoided for 48 hours and that exposure to the sun must be avoided for at least 4 weeks after the treatment and a sunblock of SPF 30 or higher must be used on the exposed skin areas. Otherwise it is possible that blotchy skin, hyper- or hypo- pigmentation might occur.*

I have been informed of the possible side effects of treatment, which include temporary erythema, sensations of heat and possible swelling, blistering or skin sensitivity and understand how and why these might occur and wish to proceed with treatment and will not hold the clinic responsible should I suffer any of these side effects.*

I agree to cooperate with the recommendations of the above clinic while I am under the care, realising that any lack of co-operation could result in less than optimum results. I certify that all information that the clinic has requested of me of a medical / health nature is correct and that is my responsibility to inform the clinic should any of these information change.*

I certify that I have read the entire informed consent and I agree to all its provisions. I certify that I have had the opportunity to ask questions and these questions have been answered to my satisfaction. I fully understand the treatment conditions and procedure.*

I agree to pay for the above mentioned services and understand that there will be no refunds for any performed services.*

I hereby authorise MADA Clinic and Spa to use my photo and/or information related to my experiences with my treatment with associated devices and products. I understand this information may be used in publications, presentations, promotional literature, advertising, social media and/or other similar ways.