EVOLVE CONSENT FORM

Patient's Name:

Treatment Sites:

I duly authorize to perform TITE / TRANSFORM/ TONE tx.

Please Initial

I understand that the device being used for skin improvement, muscle tone or cellulite treatment, of which I am consenting to be a patient receiving treatment (specify procedure).

- I understand that clinical results may vary depending on individual factors, including but not limited to medical history, skin type, patient compliance with pre- and post-treatment instructions, and individual response to treatment.

- I understand that there is a possibility of short term effects such as reddening, mild burning, swelling, temporary bruising and temporary discoloration of the skin, as well as the possibility of rare side effects such as scarring and permanent discoloration.

- When using TONE applicator minor, short term muscle spasm/pain may occur.

- These effects have been fully explained to me.

- I understand that treatment with this system involves a series of treatments and the fee structure has been fully explained to me.

- I 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.

- I confirm that I have informed the staff regarding any current or past medical condition, disease or medication taken.

- I consent to the taking of photographs and authorize their anonymous use for the purpose of medical audit, education and promotion.

- I consent to the use of before & after photos for marketing purposes.

- I certify that I have been given the opportunity to ask questions and that I have read and fully understand the contents of this consent form.

Witness:

Date: