Please review the listed contraindications and confirm that you do not have any of the following:* * Pregnant or nursing woman
* Epileptic
* Use a pacemaker
* Have a muscular or nervous disease
* Being treated for cancer
* Have orthopedic implants
* Uncontrolled diabetes
* Facial paralysis

I have no allergies to anything that I am aware of.*

I understand that I must inform my technician if there are changes to my medical history, during my series of Bela MD treatments.*

I clearly understand and accept the following:* 1. The goal of these treatments, as in any cosmetic procedure, is improvement, not
perfection. I understand my results might not be perfect, and the number of treatments may
vary.
2. There may be more treatments necessary than I anticipated.
3. There is no guarantee that expected or anticipated results will be achieved.

I understand that I might experience a scratchy, stinging sensation during the treatment.*

I understand that after the treatment my skin may appear red, which will dissipate in a few hours or less, depending on my skin’s sensitivity.*

I acknowledge that if I fail to apply an SPF (sunscreen) after treatment, that I will be more susceptible to sunburn and hyperpigmentation.*

I understand that during my treatment the use of medium frequency electromechanical stimulation and electroporation will be applied, I may sense involuntary muscle contractions and a pins and needles type sensation.*

I confirm that I have not been on Accutane for acne therapy in the last 6 months.*

I have read and understand the informed consent form and agree to treatment. I hereby give consent to receive the belaMD treatment performed by Skin Care Laser YXE.**