The physician obtained my medical history and found me eligible for treatment.
I do not have any contraindications to VIRTUE RF. These include none of the following:
- History of active skin malignancy
- Chronic skin conditions
- Currently pregnant
- Metal implant found over the site to be treated
- Heart seizures
- Pacemakers
- Active heart conditions or active cancer
- Epilepsy
- Varicose vein patient
- Metal allergy
- Have open sores, wounds or infected areas in the area to be treated
- Have tattoos or permanent make-up over the area to be treated
- Have discontinued my Retin-A, Accutane, and other Vitamin A derivative products 2 weeks prior to VIRTUE RF treatment
- Stop blood thinners 24 hours prior to VIRTUE RF treatment
I have received the following information about the technology:
- VIRTUE technology utilizes fractional radiofrequency (RF) and microneedling indicated for facial/neck/chest and back of hands, as well as small body areas.
- The VIRTUE treatment induces ablation, thus improving the appearance of rough texture, fine lines, wrinkles, and depressed scars, such as acne scars along with superficial pigments that will be ablated. The treatment also induces skin rejuvenation by heating the dermis which stimulates collagen generation and replenishment.
- The treatment requires anaesthesia 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.
- There may be alternative procedures or methods of treatment, such as fractional lasers for ablation (CO2) and lasers, IPL or RF-based systems for skin rejuvenation. Details were explained to me.
- I was told about the possible side effects of the treatment including:
- Discomfort – Some discomfort and/or pain may be experienced during treatment. A topical anaesthetic will be applied to your skin before treatment. Other forms of anaesthesia, or pain management, may also be used.
- Swelling – Swelling (oedema) of the treated area is common and may occur. This usually resolves in a few days.
- Redness – Redness (erythema) of the treated area is common and may occur. The erythema typically resolves in about two weeks.
- Skin colour changes – During the healing process, there is a possibility that the treated area may become either lighter (hypopigmentation) or darker (hyperpigmentation) in colour compared to the surrounding skin. This is usually temporary, but, on a rare occasion, it may be permanent. You should avoid sun exposure after the treatment and use sunblock.
- Milia/Acne – Ointments that occlude hair follicles, sweat ducts, or sebaceous ducts may lead to milia/acne formation. This is more common in patients with a history of cystic acne or oily skin.
- Wounds – Treatment can result in burning, blistering, or bleeding of the treated areas. It is important that you not pick or scratch the sites as this may lead to permanent scars or promote an infection. If any of these occur, please call the clinic.
- Infection – Infection is a possibility whenever the skin surface is disrupted which can lead to scarring. Proper wound care and keeping the treated area clean are important. If signs of infection develop, such as pain, heat, blisters, or surrounding redness, please call the clinic.
- Contact/allergic dermatitis or skin sensitivity – Potential increased sensitivity, irritation/itching or allergic reaction of the skin due to skin surface disruption.
- Scarring – Scarring is a rare occurrence, but it is a possibility if the skin surface is disrupted. To minimize the chances of scarring, it is IMPORTANT that you follow all post-treatment instructions provided by your clinician.
- Treatment pattern – A persistent spot size pattern may be apparent on the treated skin and usually resolves with time. In rare cases, it may be permanent.
- Petechiae – May appear for several weeks after healing and clear without treatment.
- Dilated Pores – Collagen contraction that occurs as part of the resurfacing process may also contract the skin between the pores, which widens the existing pores. This occurrence, though rare, is permanent.
- Sun Exposure/Tanning Beds/Artificial Tanning – May increase risk of side effects and adverse events.
- Allergy – There is a risk of an allergic reaction to the topical anaesthetic.
Although these effects are rare and expected to be temporary, redness and swelling may last up to 3 weeks, and are part of a normal reaction to the treatment. Burns and resulting pigmentation change and scarring are rare and may happen in dark skin that is not taken care of according to instructions. Tiny scabs may appear on the face for a few days as part of a normal healing, however, make-up may be applied as soon as 1-3 days after the session to mask them and residual redness. Any adverse reaction should be reported immediately.
- I understand that the treatment involves multiple sessions, 15 - 30 days apart, according to treatment parameters and individual response.
- I understand that I must 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 or assistants to perform such other procedures if they find them professionally desired.
- 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.
The procedures to be used to treat my conditions have been explained to me.
I have had sufficient opportunity to discuss my condition and treatment. I believe I have adequate knowledge upon which to base an informed consent.
Any questions I have asked have been answered to my satisfaction.
I authorize before, during, and after the procedure(s) the taking of photographs to be part of my patient profile that may be used for scientific or marketing purposes without disclosing my identity.
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.
