Consent

Name *

Contact Details *

Treatment *

Name of the treatment you are signing this consent form for Monalisa Laser Vaginal Rejuvenation

I am aware of the following possible experience and/or risks associated with the procedure:

• Discomfort may be experienced during and/or after the treatment
• Possibility of over heating, resulting in painful intercourse
• Some mild swelling and/or temporary redness may occur following the procedure
• Potential for transient over-active bladder
• Injury to bowel and bladder
• Scarring is rare, but is a possibility if the skin surface is disrupted
• Although very rare, burns can occur and may require additional care at my own expense
• Infection (urinary tract, vaginal infection) is uncommon, but should it occur, treatment with antibiotics and/or surgical intervention may be required. Infection can further increase the risk of scarring. Proper wound care is important in the prevention of infection. If signs of infection such as pain, heat, blisters, or surrounding redness please contact your health professional immediately.

To my knowledge, I have not had an abnormal pap report within the last year.

The nature and effects of the procedure, the risks, the ramifications, complications, as well as alternative methods of treatment have been fully explained to me by the physician or designated person and I understand them. The benefits of the proposed procedure, along with the probability of success have also been discussed with me. I have been given the opportunity to ask questions and have received satisfactory answers. certify that I have read the above authorization and that I fully understand it.