#InformedConsent
#10mm
#15mm
#25mm
#ReadCarefully
This form covers Luxora by InMode — a radiofrequency device that contracts soft tissue and treats laxity and/or adiposity. This is a medical procedure performed under local + tumescent anesthesia with small incision ports. Please read every section carefully and initial each. Do not sign anything you don't fully understand. The form below is built on InMode's official sample consent template, adapted for our practice.
⚠ HANDPIECE + AREA SELECTION (must be completed before signing)
My treatment today will be performed using the following Luxora handpiece(s):
10 MM
Face / jawline / submental
15 MM
Small body areas (neck, bra rolls, knees, small flanks)
25 MM
Large body (abdomen, flanks, back, thighs)
Specific area(s) being treated
§1 · THE PROCEDURE · what Luxora is and how it works
WHAT THIS TREATMENT IS
I request and authorize Ryan Kent, FNP-BC (Medical Director), or designated trained staff under his supervision, to perform a procedure with the Luxora Quantum handpiece. The handpiece is indicated for use in dermatological and general surgical procedures for electrocoagulation/contraction of soft tissue and hemostasis. The result is heating of the fibrous septa and papillary dermis, resulting in collagen contraction.
This procedure is being used to treat my condition/medical diagnosis of laxity and/or adiposity.
The treatment may involve applying heat to the adipose (fat) tissue and dermis using radiofrequency for therapeutic purposes and may be combined with lipoaspiration (lipoaspiration may be used in conjunction if the provider determines it is necessary).
This device is FDA-cleared for soft tissue coagulation.
§1 — The areas for 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.
§2 · REALISTIC EXPECTATIONS · results vary, no guarantees
WHAT I UNDERSTAND ABOUT RESULTS
The practice of medicine and surgery is not an exact science. Although Luxora is effective in most cases, no results have been guaranteed.
I acknowledge that imperfections might ensue and that the operative result may not meet my expectations.
Skin tightening may not be fully apparent for 6–12 months after this procedure.
Results vary from individual to individual, and results are age-dependent.
Multiple sessions may be required to achieve desired outcomes.
Skin irregularities may occur with any lipoaspiration treatment if performed in conjunction.
§2 — I understand that no specific outcome can be guaranteed, that results take 6–12 months to fully appear, and that individual response varies. I have realistic expectations.
§3 · RISKS, SIDE EFFECTS + COMPLICATIONS · these are real and you must understand them
⚠ READ CAREFULLY. Per the InMode sample consent, the following are the documented possible experiences and risks associated with this procedure.
EXPECTED + POSSIBLE EFFECTS
Anesthesia risk — I consent to local + tumescent anesthesia. All forms of anesthesia involve risks and the possibility of complications, injury, or death.
Discomfort during and/or after treatment
Bruising and/or swelling following the procedure — should resolve in days, weeks, or months
Temporary redness (erythema) + swelling of treated area
Drainage from incision ports for 1–3 days
Bruising/ecchymosis may last 7–10 days or more
Substantial edema may last 1–3 weeks
Numbness, tingling, itching, tenderness in treated areas — gradually regained after 4–16 weeks or occasionally longer
Burning or heat sensation in facial or thin skin areas
SERIOUS COMPLICATIONS
Nerve injury — facial and body branches — weakness of affected areas
Hyperactivity — temporary change in smile or facial expression
Temporary numbness/tingling in treated area
Scarring — rare but possible if skin surface is disrupted
Burns — although uncommon, can occur
Infection — rare, but should it occur, treatment with antibiotics and/or surgical intervention may be required. Infection can further increase the risk of scarring.
Skin irregularities — if lipoaspiration is performed in conjunction
Pigmentation changes — hyper- or hypo-pigmentation
Damage to natural skin texture — crust, blister, burn
WARNING SIGNS: Proper wound care is important in the prevention of infection. If signs of infection — pain, heat, blisters, or surrounding redness — develop, call the office immediately. I understand the importance of pre + post-treatment instructions and that failure to comply may increase the possibility of complications.
§3 — I am aware of the possible experiences and risks associated with this procedure as listed above, including risks of anesthesia, infection, scarring, burns, nerve injury, and pigmentation changes. I understand some complications may be permanent.
§4 · POTENTIAL CONCURRENT LIPOASPIRATION · additional consent if applicable
LIPOASPIRATION CONSENT
Per the InMode sample consent: I understand that lipoaspiration may occasionally be used in conjunction with the treatment if the Medical Director determines it is necessary to do so.
I understand that skin irregularities may occur with any lipoaspiration treatment.
YES — I authorize concurrent lipoaspiration if the Medical Director determines it is necessary
NO — I do not authorize concurrent lipoaspiration; please discuss with me first if this becomes necessary
§4 — I have made my choice regarding concurrent lipoaspiration as indicated above.
§5 · MEDICAL HISTORY + CONTRAINDICATIONS · honest answers protect you
I CONFIRM I HAVE DISCLOSED + DO NOT HAVE
To my knowledge, I have disclosed my complete medical history including all of the following per the InMode contraindications list:
No pacemaker, AICD, or electronic implant
No metal plates, screws, or piercings in tx area
No current/history of skin cancer or any cancer
Not pregnant or breastfeeding
No severe cardiac, liver, kidney disease
No epilepsy or uncontrolled hypertension
No HIV, AIDS, or immunosuppression
No active skin infection in tx area
No history of keloids or abnormal wound healing
No bleeding disorders / not on anticoagulants (last 10 days)
No surgery in tx area within last 3 months
No Accutane (isotretinoin) within last 6 months
No Herpes Simplex history (or prophylaxis taken)
No filler in tx area within 6 months
No fat-dissolving injection in tx area within 3 months
No tattoo / permanent makeup in tx area
No recent tanning (sun, beds, self-tanner — last 2 weeks)
No NSAIDs in last 7 days
No diabetes / thyroid disorder uncontrolled
Disclosed all current medications + allergies
WITHHOLDING MEDICAL HISTORY can lead to serious complications. I am responsible for providing accurate and complete information.
§5 — I confirm that I have informed the staff regarding any current or past medical condition, disease, or medication taken. I have no contraindications I have not disclosed.
§6 · PHOTOGRAPHY AUTHORIZATION · clinical photos are part of medical record
PHOTOGRAPHY CONSENT
Per the InMode sample consent: I consent to have clinical photographs taken before, during, and after my procedure. I understand that these photographs are an important part of my medical record.
YES — I consent to clinical photography for my medical record (REQUIRED)
Optional educational/marketing use (separate consent):
YES — I consent to use of these photographs, with my identity not revealed (anonymous), for the education of future patients, professional clinical presentations, and medical journals
YES — face-visible marketing use (Hello Gorgeous social media + website)
NO — clinical record only, no marketing use
REVOCATION: Marketing/educational consent can be revoked at any time by written request. Clinical chart photos remain part of permanent medical record.
§6 — I have made my photography choices and understand my rights to revoke marketing/educational consent at any time.
§7 · COMPLIANCE + FINANCIAL RESPONSIBILITY · your role + payment
PRE + POST-CARE COMPLIANCE
Follow ALL pre-treatment instructions per the Pre-Treatment Guide
Complete all prescribed medications (antiviral, antibiotic, etc.) as directed
Arrange a driver home — REQUIRED
Wear my compression garment as instructed (3 weeks minimum body areas)
Follow ALL post-treatment care instructions
Avoid sun, heat, NSAIDs, alcohol as instructed
Attend all follow-up appointments
Contact Hello Gorgeous immediately with any concerns
FINANCIAL TERMS
Luxora is an elective cosmetic procedure not covered by medical insurance.
Payment is due at time of service unless arranged.
Financing options (CareCredit, Cherry) are available if applied + approved.
Fees are non-refundable once treatment is performed.
Compression garments may be included or sold separately depending on package.
Complications, if they occur, may require additional appointments or out-of-pocket cost for related care or specialist referrals.
Touch-up or maintenance treatments are at additional cost unless stated in package.
§7 — I have received the Pre + Post-Treatment Care Guides. I agree to follow all instructions, understand the financial terms, and accept responsibility for payment.
§8 · MANUFACTURER WAIVER · standard InMode language
INMODE WAIVER
Per the InMode sample consent: I agree to waive, release, discharge, and covenant not to sue Invasix, Inc. d/b/a InMode ("InMode") and its employees, agents, and representatives from any liability, loss, cost, damage, expense, claim, or lawsuit whatsoever for any and all injury, loss, illness, harm, cost, expense, or damage related to the treatment, including any negligent acts or conduct by InMode and its agents, employees, and/or representatives (collectively, "Claims").
§8 — I have read and understand the InMode manufacturer waiver above.
§9 · CONSENT DISCLAIMER + FINAL AUTHORIZATION
DISCLAIMER
Informed Surgical Consent Forms communicate information about the proposed treatment of a condition, including disclosure of risk and alternative treatment(s). The informed consent process attempts to define principles of risk disclosure that should generally meet the needs of most patients in most circumstances.
What the surgical and office staff have discussed with me and have been included in this consent are the material risks, both common and uncommon, that the doctor feels a reasonable person would want to know, understand, and consider in deciding if the proposed treatment of a condition is something they would like to proceed with.
However, informed surgical consent should not be considered all-inclusive when defining other methods of care and risks encountered. The staff may provide additional or different information based on all the facts in my particular case and the state of medical knowledge.
I, THE UNDERSIGNED, certify that I have been fully informed of the nature and purpose of the procedure, expected outcomes, and possible complications, and I understand that no guarantee can be given as to the final result obtained. I am fully aware that my condition is of cosmetic concern and that the decision to proceed is based solely on my expressed desire to do so. The nature and effects of the procedure, the risks, 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. I have been given the opportunity to ask questions and have received satisfactory answers. I CONSENT TO THE PROCEDURE AND/OR TREATMENT AND THE ABOVE-LISTED ITEMS. I AM SATISFIED WITH THE EXPLANATION.
Patient or Person Authorized to Sign for Patient
I have read and fully understand the contents of this consent form.
Provider Signature (Medical Director or Authorized Designee)
I have reviewed this consent with the patient and answered their questions.
Witness Signature
Witness attests patient signed freely and knowingly.
COPY PROVIDED: I acknowledge receipt of a copy of this signed consent form, plus the Pre-Treatment Guide and Post-Treatment Care Guide.