ThermiSmooth Treatment Consent
THE MEDSPA AT RALEIGH PLASTIC SURGERY CENTER
ThermiSmooth Treatment Consent
Non-invasive Treatment for Skin Laxity, Wrinkle Improvement and Smoothing
There is the possibility that additional risk factors of radiofrequency skin treatments may be discovered.
The results of performing ThermiSmooth treatments in combination with other treatments is unstudied
and unknown.
It has been explained to me that this is a cosmetic procedure and not covered by insurance. 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 chemical peels, filler injections, or no treatment at all.
As mentioned before, there is no guarantee of results and no refund of payments for the procedure will
be made.
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
understand this document and give my consent to receive treatment with the ThermiRF radio frequency system.
Patient Name Signature Date
Physician Name Signature Date
