CONSENT FORM AND PRE-POST CARE INSTRUCTION FOR VAGINAL REJUVENATION TREATMENT – Alma CO2 Lasers

TREATMENT OVERVIEW

Vaginal rejuvenation using Femilift (fractional CO₂ laser) and Femitight (radiofrequency) helps stimulate collagen production, restore vaginal tissue elasticity, and improve symptoms of dryness, laxity, and mild urinary incontinence. This is a non-invasive, outpatient procedure typically performed without anesthesia.
Most patients require a series of 3-4 treatments, spaced 4–6 weeks apart, followed by annual maintenance sessions.
Prophylactic oral antiviral agents for the prevention of Herpes Simplex Virus reactivation will be prescribing to patients if needed.
There may be very mild discomfort associated with the treatment. We will apply topical numbing to help patients feel as comfortable as possible.

CONTRAINDICATIONS

You are not a candidate for this treatment if you:

• Are pregnant or nursing

• Have an active vaginal, urinary, or pelvic infection or cancer

• Have untreated cervical or vaginal lesions

• Have a pacemaker or other implanted electronic device

• Are taking immunosuppressive medications

• Have a history of abnormal scarring or wound healing

• Are within 6 weeks postpartum

RISKS & SIDE EFFECTS

While rare, side effects may include:

• Mild discomfort or burning sensation

• Light spotting or watery discharge

• Temporary swelling or redness

• Vaginal dryness or irritation

• Infection (very rare)

• Scarring or pigmentation changes (extremely rare)
  Most side effects resolve within 1–3 days.

PRE-TREATMENT CHECKLIST

Please review and confirm:
☐ I have had a recent gynecological exam that is within the current guideline of THE AMERICAN CANCER SOCIETY FOR THE PREVENTION AND EARLY DETECTION OF CERVICAL CANCER prior to the Vaginal Rejuvenation treatments.
☐ I am not currently menstruating or experiencing abnormal vaginal bleeding.
☐ I have no active vaginal or urinary tract infection.
☐ I have disclosed all medications, allergies, and health conditions.
☐ I have urinated prior to the treatment.
☐ I understand that sexual activity should be avoided 24–48 hours before the procedure.
☐ I have reviewed all information regarding risks and results with my provider.

POST-TREATMENT CARE INSTRUCTIONS

For the first 5 days after treatment, please:

• Avoid sexual intercourse, using tampons or inserting anything vaginally

• A transient inflammatory reaction is expected after the procedure (e.g. sensation of heat). Usually it is resolved within 24 hours and does not last more than 72 hours.

• Avoid hot baths, saunas, or pools

• Wear loose, breathable underwear

• Avoid vigorous physical activity

• Keep the area clean and dry

• Use only approved external soothing products if needed

• Call your provider if you experience unusual discomfort, bleeding, or signs of infection within 48 hours

PATIENT DECLARATION

§ I have disclosed my full medical history and any current medications.
§ I understand this treatment is elective and not guaranteed to produce specific results.
§ I have had the opportunity to ask questions and received satisfactory answers.
§ I understand the risks, benefits, and aftercare involved.
§ I understand that multiple sessions may be required for optimal results.
§ I confirm I am not pregnant or trying to become pregnant.

VOLUNTARY CONSENT

I have read and fully understand the information in this consent form. I voluntarily request and consent to the vaginal rejuvenation treatment using Alma Lasers Femilift and Femitight. I release La Bella Laser & Slimming and its practitioners from any liability associated with reasonable medical outcomes related to this procedure.