CATALEYA AESTHETICS
Forma / Forma Plus Treatment Consent
This form is designed to give you the information you require to make an informed choice of whether or not to undergo treatment with Forma or Forma Plus technology. 
•	I hereby authorize Dr. Reyes-Villa and associates to perform Forma / Forma Plus procedure.
•	The physician obtained my medical history and found me eligible for treatment.
•	I have received the following information about the technology:
 
o	Forma and Forma Plus™ is a non-invasive technology that utilizes radiofrequency (RF) and is indicated for skin tightening of body areas, such as arms, back, abdomen, buttocks, thighs and knees.
o	Forma and Forma Plus™ treatment induces heating of the dermal and sub-dermal layers which stimulate a reaction leading to collagen generation and replenishment. 
o	The treatment creates a warm sensation over the skin surface. 

•	I understand that taking the treatment course is my choice and that I am free to withdraw at any time, without giving any reason.
•	There may be alternative procedures or methods of treatment that cause skin tightening by heating the tissue, such as lasers, IPL, and alternate RF technologies.
•	I was told about the possible side effects of the treatment including local pain, skin redness (erythema), swelling (edema), damage to the natural skin texture (crust, blister, burn), change of pigmentation (hyper- or hypo-pigmentation) and scarring. Although these effects are rare and expected to be temporary, any adverse reaction should be reported immediately.
•	I understand that the treatment involves 6-8 weekly sessions, and that maintenance sessions may be required periodically, once in a few months, according to individual response.
•	I understand that I must comply with the treatment schedule, otherwise, results may be compromised.
•	I understand that not everyone is a candidate for this treatment and results may vary. Therefore, there is no guarantee as to the results that may be obtained.
•	Forma / Forma Plus Patient Instructions copy has been provided to me and I understand recommended            Pre-procedure and Post-Procedure Care.
•	Any questions I may have asked have been answered to my satisfaction.
•	I have been provided a copy of Notice of Privacy Practices at Cataleya Aesthetics.

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       Patient Name (please print) 			 			Date and Time

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       Patient or Parent/Guardian Signature                               Date and Time
      
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       Physician/Associate Signature					       	Date and Time