Morpheus InMODE Consent form

YOU NEED ONLY FILL/SIGN THIS FORM ONCE.

This form is designed to give you the information you require to make an informed choice of whether or not to undergo treatment with MORPHEUS Inmode technology.

I hereby authorize Sonia Felix and/or associates to perform the MORPHEUS Inmode treatment.

I have received the following information about the technology:

• MORPHEUS Inmode technology utilizes fractional radiofrequency (RF) indicated for face, neck, abdomen, arms, above the knees, chest, as well as other small body areas.

• MORPHEUS Inmode treatment induces ablation, thus improving the appearance of rough texture, fine lines, wrinkles, and depressed scars, such as acne scars along with superficial pigments. The treatment induces skin rejuvenation by heating of the dermis which stimulates collagen generation and replenishment as well as closure of superficial fine blood capillaries.

• The treatment requires anesthesia that involves topical cream, injections, or sedation according to the treatment parameters and the physician's discretion.

• I understand that taking the treatment course is my choice and that I am free to withdraw at any time, without giving any reason.

• I was told about the possible side effects of the treatment including local pain, skin redness (erythema), swelling (edema), damage to the natural skin texture (crust, blister, burn), change of skin pigmentation (hyper- or hypo-pigmentation), and scarring. Although these effects are rare and expected to be temporary, redness and swelling may last up to 3 weeks. Burns and resulting pigmentation change and scarring are rare and may happen in persons with darker skin. Tiny scabs will appear on the face as part of normal healing. Make-up may be applied 2-3 days after the treatment. Any adverse reaction should be reported immediately.

• I understand that the treatment involves 1-3 sessions, based on the individual assessment, response to treatment and aesthetic goal.

• Sessions are spaced 3-6 weeks apart.

• I understand that certain medical conditions and medications may contraindicate treatments. I have disclosed my full medical history to the provider.

• I understand that I have to comply with the treatment schedule, otherwise results may be compromised • I recognize that during the course of the procedure unforeseen conditions may necessitate different procedures than this above and I authorize the physician to perform such other procedures if they find them professionally recommended or necessary.

• I understand that not everyone is a candidate for this treatment and results may vary. Therefore, there is no guarantee as to the results that may be obtained.

• Morpheus Inmode patient instructions copy has been provided to me and I understand recommended post-procedure care and consideration.

• I UNDERSTAND THAT BY BOOKING A MORPHEUS APPOINTMENT OR PACKAGE THAT I AM AGREEING TO THESE CONDITIONS AND REQUIREMENTS ABOVE.

• I UNDERSTAND THAT BY BOOKING A MORPHEUS PACKAGE, I AM PAYING A NON-REFUNDABLE DEPOSIT THAT IS APPLIED TO MY BALANCE AND THAT THE REST OF THE BALANCE IS DUE THE DAY OF MY APPOINTMENT. NO EXCEPTIONS.

• I UNDERSTAND THAT BY BOOKING A MORPHEUS APPOINTMENT OR PACKAGE, I AM AWARE THERE ARE NO REFUNDS. NO EXCEPTIONS.

• Any questions I may have asked have been answered to my satisfaction.