Consent for Vaginal health laser treatment

Informed Consent For Treatment for Vaginal Health with the Phoenix CO2 Laser System

I, ___________________________________, authorize and consent to the treatment for vaginal health with the Phoenix CO2 Laser.

I have been advised by, _____________________________________________ of

_________________________________________ of the purported advantages and disadvantages associated with this treatment.

I understand that treatment with this laser system varies from patient to patient and that that more that 1-treatment may be required.

No guarantees have been made to me regarding the outcome of the treatment or any improvements in my condition due to the procedure._________ (initials)

I understand that the possible benefits are the reduction of pain during intercourse, reduction of itchiness in the vaginal area and increased lubrication in the vaginal area (vaginal health). _________ (initials)

Due to the brilliance of the laser light energy used, I agree to wear eye protection to shield my eyes. ________ (initials)

I have been given the opportunity to ask questions and have received satisfactory answers to these questions.________ (initials)

I hereby authorize the taking of photographs. These photographs may be used to demonstrate the results this laser produces. ________ (initials)

I hereby indemnify and hold harmless Rohrer Aesthetics, Inc. and their employees, the treating technician and ____________________________________ from any and all liability, damages, cost and expenses arising from or out of the use Phoenix-CO2 Laser for the vaginal health treatment.. _______ (initials)

With all of the above information understood, I am choosing to be treated with the Phoenix CO2 Laser.

___________________________________ Signature

____________________________________ Print Name

____________________________________ Date

____________________________________ Witness