I request and authorize Dr. Zimmerman or designated person to perform the following procedure utilizing temperature controlled radio frequency technology.
The areas from treatment have been reviewed with me today and I am in agreement. I have been thoroughly and completely advised regarding the objectives of the procedure. I understand that the practice of medicine and surgery is not an exact science and although these procedures are effective in most cases, no results have been guaranteed. I acknowledge that imperfections might ensue and that the operative result may not live up to my expectations. I understand that clinical results may very based on many variables such as age, lifestyle, and current conditions.
The treatment will involved applying heat to the vulvar and vaginal tissues using radio frequency for therapeutic purposes.
I am aware of the following possible experiences and/or risks associated with the procedure:
While I understand this technology does not have any manufacturer declared contradictions, it is advised to not treat patients with the following conditions:
Your physician may suggest alternative treatment if you have any of the following conditions:
I consent to having clinical photographs taken before, during, and after my treatment. I understand that these photographs are an important part of my medical record.
In addition, I consent to the use of these photographs, without my identity being revealed, for the education of future patients, professional clinical presentations, and medical journals.
The nature and effects of the procedure, the risk, and the ramifications, complications, as well as alternative methods of treatment have been fully explained to me by the physician or designated person, and I understand them. The benefits of the proposed procedure, along with the probability of success have also been discussed with me. I have been given the opportunity to ask questions and have received satisfactory answers. I certify that I have read the above authorization and that I fully understand it.