I authorize Dr. Zimmerman/Dr. Lee and staff to perform fractional CO2 treatment on me in an effort to treat vaginal health-related symptoms related to menopausal transition to post menopause / other.
The nature and effects of the procedure, as well as alternative methods of treatment have been fully explained to me and I understand them.
I understand that there is a possibility of side effects or complications. I am aware that careful adherence to all advised instructions will help reduce this possibility.
The procedure as well as potential benefits and risks have been thoroughly explained to me and I have had all my related questions answered.
Pre and post-care instructions have been discussed and are completely clear to me.
I understand that results may vary with each individual and acknowledge that it is impossible to predict how I will respond to the treatment. If no alleviation of vaginal health-related symptoms is observed or unsatisfactory resolution of my symptoms, I understand that it might be necessary or appropriate to revert to replacement therapies.
I agree to review the following laser pre-treatment compliance checklist along with my physician and bring accurate and updated data, to the best of my knowledge.
I understand the below list of possible short-term effects post procedure:
Please answer the following questions to the best of your abilities:
My signature certifies that I have duly read and understood the content of this informed consent form, and gave the accurate information as to my health condition. I hereby freely consent to the AcuPulse® FemTouch™ procedure.