This form is designed to give you the information you require to make an informed choice of whether or not to undergo treatment with Vivace technology. If you have any questions before your treatment, please feel free to ask.
I hereby authorize Dr. Zimmerman, and/or such assistants as may be selected to perform the Vivace procedure.
The physician obtained my medical history and found me eligible for treatment.
I have received the following information about the technology:
The procedures to be used to treat my conditions have been explained to me.
I have had sufficient opportunity to discuss my condition and treatment. I believe I have adequate knowledge upon which to base an informed consent.
Any questions I may have asked have been answered to my satisfaction.
I authorize before, during and after the procedure(s) the taking of photographs to be part of my patient profile that may be used for scientific or marketing purposes without disclosing my identity.
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.