CoolTone Treatment Consent Form

Patient Information

First name

Last name

Today's Date

I certify that I am a competent adult of at least 18 years of age

I certify that I am a minor under the age of 18 and understand that the consent of my parent/legal guardian will also be required before treatment.

SECTION 1: OVERVIEW

I understand the CoolTone® treatment is a noninvasive procedure that is intended to firm and tone the treatment area by delivering controlled electromagnetic stimulation to induce strong muscle contractions. This procedure does not replace traditional healthy behaviors, such as exercise and diet.

I understand the CoolTone® procedure is intended to provide noninvasive electromagnetic stimulation for the improvement of abdominal tone, strengthening of the abdominal muscles, development for firmer abdomen, and strengthening, toning, and firming of buttocks and thighs. Results may vary.

WHAT YOU CAN EXPECT

Contraindications:

Active applicator should never be placed over implanted electrical devices like cardiac pacemakers, cochlear implants, intrathecal pumps, hearing aids, etc.

CoolTone should be used with caution in patients with Graves’ disease, active bleeding disorders, or seizure disorders.

Women who are close to menstruation may find that it comes sooner, or cramping is increased/intensified with CoolTone treatments. Therefore, it is not recommended to undergo treatment during this time of the month. I understand that this and other unknown side effects may occur.

Do you currently have or have had any of the following ?

Implanted electrical devices:

Cardiac pacemakers

Yes

Cochlear implants

Yes

Intrathecal pumps

Yes

Hearing aids

Yes

Defibrillators

Yes

Neurostimulators

Yes

Drug pumps

Yes

Any other implanted electrical devices?

Yes

Graves’ disease

Yes

Active bleeding disorders

Yes

Seizure disorders

Yes

Malignant tumor

Yes

Heart problems

Yes

Hemorrhagic conditions

Yes

Epilepsy

Yes

Epilepsy

Yes

Pulmonary insufficiency

Yes

Fever (currently)

Yes

In the treatment area:

Areas of skin that lack normal sensation

Yes

Metal or electronic implants

Yes

Recent surgical procedure

Yes

For female:

Menstruating (currently)

Yes

Pregnant

Yes

Results

I understand results vary from person to person and that I may decide additional treatments are necessary to achieve your desired outcome. Although highly unlikely, I understand it is possible that I will not experience any noticeable result from the procedure.

As with most medical procedures, there are risks and side effects. These have been explained to me in detail. I have read the above information, and I give my consent to be treated with the CoolTone® procedure by the physician(s) in this practice and his/her designated staff.

SECTION 2: CONSENT

I understand pictures will be obtained for medical records. If pictures are used for education and marketing purposes, all identifying marks will be cropped or removed.

I consent to allowing Mirage Salon & MedSpa to use the photographs on their social media for promotional purposes.

By signing below, I hereby authorize my CoolTone® physicians, healthcare professionals, or other healthcare providers (collectively, my “Healthcare Providers”) to disclose and transmit my protected health information to Allergan Aesthetics and/or its designated service providers (collectively, “Allergan Aesthetics”) in order for Allergan Aesthetics to: (i) help enable my treatment and provide me with communications about my treatment; (ii) operate, administer, register me in and/or provide me with access to Allergan Aesthetics programs and services; (iii) identify products and services that may be of interest to me and to provide me with communications about any such products and services; and (iv) develop, evaluate, and improve products, services, materials, and programs related to my condition or treatment.

I authorize any protected health information disclosed by my Healthcare Providers pursuant to this authorization to be transmitted electronically in whatever form and through whatever media, including the internet, as required by the purposes set forth.

This authorization is made pursuant to 45 CFR § 164.524.

Patient Signature

Forms

CoolTone Treatment Consent Form

Patient Information

SECTION 1: OVERVIEW

WHAT YOU CAN EXPECT

SECTION 2: CONSENT

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