BBL HEROic informed consent I authorize Perpetual Aesthetics and Wellness, to perform BBLⓇ HEROic™ treatments on the following area(s) of my body: Area(s) of treatment * Face Chest Neck Body I understand that the Sciton BBL HEROic is intended for benign vascular and pigmented lesions, and/or permanent hair reduction and that clinical results may vary in different skin types. I understand that there is a possibility of rare side effects such as scarring and permanent discoloration as well as short term effects such as reddening, mild burning, temporary bruising, and temporary discoloration of the skin. These effects have all been fully explained to me. Based on the experience of other physicians we have found that those people who tend to sunburn rather than tan, usually obtain good results on the first and subsequent visits. On the other hand, those who tan more easily tend to have more variation in their results. Some patients in this category will experience partial results and some will experience no improvement at all. * I understand that the treatment by the Sciton BBL HEROic system involves payment, and the fee structure has been fully explained to me. * I also understand that there are other options for treatment that are available and each of these other options has been fully explained to me. Photography * Consent to photographs and other audio-visual and graphic materials before, during, and after the course of my therapy to be used for medical, marketing, and education purposes. Although the photographs or accompanying material will not contain my name or any other identifying information, I am aware that I may or may not be identified by the photos. Yes No * I have read and understand all information presented to me before signing this consent form. I have been given an opportunity to have all of my questions answered to my satisfaction. I understand the procedure and accept the risks. I agree to the terms of this agreement. First Name Last Name Date * MM DD YYYY Email * Thank you!
