Informed Consent for TempSure® Wrinkle and Cellulite Treatments - Page 2 of 2
Advance Biomedical Treatment Center
35 Jolley Drive Suite 102 Bloomfield CT 06002
Tel (860)242-2200 Fax (860)242-2212
Slight discomfort may be experienced while undergoing treatment. Typically the discomfort is mild and
temporary during the procedure and localized within the treatment area. During the treatment you will feel
warmth and heat. The skin temperature is automatically determined by the temperature sensor at the tip of
the probe. For benefits to be achieved, skin temperature has to reach 39 C and sustained for at least 3
minutes. Thirty nine degrees centigrade is the temperature considered as high grade fever; it is generally
tolerable. For best results, the medical assistant will try to raise the temperature to 41C. You will be asked to
provide ongoing feedback to the individual performing the treatment. Feel free to let the medical
assistant/physician know if discomfort is reaching intolerable level. There will be no anesthetic (local, oral, or
systemic) used prior to or during the treatment. Additionally, if you have nerve sensitivity to heat anywhere in
the treatment area, you should not be treated. Inadequate or impaired feedback may lead to burns or injury.
To reiterate ongoing feedback should be provided by you to the individual performing the treatment to avoid
excessive discomfort.
After Treatment:
1. Studies indicate the possible side effects of TempSure™ RF System are usually treatment-site related
and include mild discomfort during the procedure.
2. Mild swelling and redness may occur which typically goes away within 2 to 24 hours.
3. Photo-sensitive pigmentation may occur. Diligent protection from sun exposure and application of
sunscreen for two to three weeks after treatment will minimize pigmentation changes.
4. A regimen to moisturize and soothe skin for one week post-treatment is recommended.
5. Drink a minimum of 80 oz. of water a day. Adequate hydration always promotes healthy skin with
fewer wrinkles and less eye bags.
There is the possibility that additional side effects of radiofrequency skin treatments may be discovered in the
future. The use of RF wrinkle treatments in combination with other treatments is unstudied and unknown.
Disclaimer and Consent Form:
1. It has been explained to me that this is a cosmetic procedure and not covered by insurance.
2. It has been explained to me that more than one treatment may be recommended to achieve the best
results and that there are other treatment options such as microdermabrasion, chemical peels, filler
injections, or no treatment at all.
3. As mentioned before, there is no guarantee of results and therefore no refund of payments for the
procedure will be made.
4. While my physician and the staff will take reasonable precautions to ensure my safety, I am willing to
assume the risks of treatment whether known or unknown.
My signature below signifies that all of my questions have been answered by the physician or consultant. I
understand the risks, complications, expected results, and expense of the treatments. I have read and
understood this document and give my consent to receive treatment with the TempSure™ RF System.
Client Name__________________________________________ Date of Birth _______________
Signature____________________________________________ Date Signed ________________
Practitioner Name_____________________________________
Signature____________________________________________ Date Signed ________________
