Informed Consent

Patient name

Treatment sites

I duly authorize

to perform

treatment

I understand that the

I understand that clinical results may vary depending on individual factors, including but not limited to medical history, skin type, patient compliance with pre- and post-treatment instructions, and individual response to treatment.

I understand that there is a possibility of short-term effects such as:

PAIN & DISCOMFORT - The level of pain and discomfort varies with a person’s tolerance, and both may be experienced during treatment.

BURNS - Laser energy can produce burns. Adjacent structures including the eyes may be injured or permanently damaged by the laser beam. Burns are rare yet represent the effect of heat produced within the tissues by laser energy. Additional treatment may be necessary to treat laser burns.

BREDNESS & SWELLING - Short term redness (erythema) or swelling (edema) of the treated area is common and may occur. An urticarial (hive-like) reaction may occur as well.

PURPURA/BRUISING - Purpura (bruising) is a transient phenomenon that usually resolves with time.

HEMOSIDERIN STAINING - (Iron leaking into tissue from blood breakdown) may occur and usually resolves over time, but it may be permanent.

SKIN SENSITIVITY - Itching, tenderness, or exaggerated responses to hot or cold temperatures may occur. This typically resolves during the healing process, but in rare situations it may be chronic.

WOUND HEALING - Treatment can result in burning, blistering, or bleeding of the treated areas resulting in a wound. If this occurs, please contact our office.

INFECTION - Infection is a possibility whenever the skin surface is disrupted, though proper wound care should prevent this. If signs of an infection develop, such as pain, heat or surrounding redness, please contact our office at

Herpes simplex virus infections (cold sores) around the mouth can occur/

BLEEDING - It is possible, though unusual to experience bleeding or pinpoint bleeding during or after treatment. Should any post-treatment pinpoint bleeding or bleeding occur, please contact our office immediately. Products and medications such as aspirin, anti-inflammatories and blood thinners can increase the risk of bleeding.
Non- prescription herbs and dietary supplements can also increase the risk of bleeding. It is sometimes advised or recommended that you avoid taking any blood thinners seven to fourteen days prior to and/or after your treatment. Speak to your provider before stopping any medications.

PIGMENT CHANGES (Skin color) - There is a possibility that the treated area can become either hypopigmented (lighter or white) or hyperpigmented (darker) in color compared to the surrounding skin. This is usually temporary but can be permanent.

ACCUTANE (Isotretinoin) - Accutane is a prescription medication used to treat certain skin diseases. If you have ever taken Accutane, you should discuss this with your treatment provider. This drug may impair the ability of skin to heal following treatments for a variable amount of time even after the patient has ceased taking it. Individuals who have taken this drug are advised to allow their skin adequate time to recover from Accutane before undergoing skin treatment procedures.

FIRE - Inflammable agents, surgical drapes and tubing, hair, and clothing may be ignited by laser energy. Laser energy used in the presence of supplemental oxygen increases the potential hazard of fire. Some anesthetic gases may support combustion.

EPIDERMAL CRUSTING - Pigmented lesions may crust or scab as part of the healing process. It is important not to pick or disturb the crusts as they heal. They may require medical attention if sensitivity or redness occurs.Crusts will typically slough off 1-3 weeks after treatment.

LASER SMOKE (Plume) - Laser smoke is noxious to those who encounter it. This smoke may represent a possible biohazard.

SKIN TISSUE PATHOLOGY - Laser energy directed at skin lesions may potentially vaporize the lesion. Laboratory examination of the tissue specimen may not be possible.

VISIBLE SKIN PATTERNS - Gentle Pro laser devices may produce visible patterns within the skin. The occurrence of this is not predictable.

DAMAGED SKIN - Skin that has been previously treated with chemical peels or dermabrasion, or damaged by burns, electrolysis (hair removal treatments), or radiation therapy may heal abnormally or slowly following treatment by lasers. The occurrence of this is not predictable. Additional treatment may be necessary. If you have ever had such treatments, you should inform your treatment provider.

SCARRING - Scarring is a rare occurrence, but it is a possibility whenever the skin surface is disrupted. To minimize the chances of scarring, it is IMPORTANT that you follow all post-treatment instructions carefully.

TEXTURAL CHANGES/CUTANEOUS INDENTATIONS - Textural and/or skin changes may occur because of treatment.

LEUKOTRICHIA - Temporary or permanent gray hair.

PARADOXICAL HAIR GROWTH - Stimulation of terminal hair growth following photo-epilation can occur within or adjacent to treated area.

UNDESIRERABLE HAIR REDUCTION - Hair reduction may occur at treatment sites. This is typically temporary but can be permanent.

ALLERGIC REACTIONS - In some cases, local allergies to products used during or after treatment such as adhesive, numbing agents, topical preparations and topical post-care have been reported. Systemic reactions which are more serious may occur to drugs used during the procedure. Allergic reactions may require additional treatment.

EYE EXPOSURE - Eye injury is possible from laser procedures. Protective eyewear (shields or goggles) will be provided. It is important to keep these on always during the treatment to protect your eyes from injury.

SUN EXPOSURE/ TANNING BEDS/ ARTIFICIAL TANNING - May increase risk of side effects and adverse events. It has been advised that you discontinue and avoid UV exposure and artificial tanning before, during, and after your treatment and recommended that you discontinue this practice all together as the effects of the sun are damaging to the skin. A broad spectrum (UVA/UVB) sunscreen should be used to prevent further pigmentation.
Exposing the treated areas to sun may result in increased scarring, color changes, and poor healing. Patients who tan, either outdoors or in a salon, should inform their treatment provider and either delay their treatment or avoid UV exposure until your provider says it is safe to resume. The damaging effects of UV exposure occurs even with the use of sunscreen or clothing coverage.

TREATMENTS - The number of treatments vary but multiple treatments are always required. The number of treatments needed to clear your pigmented lesion is unknown.

LACK OF PERMANENT RESULTS - Skin treatments may not completely improve or prevent future skin disorders, lesions, or wrinkles. No technique can reverse the signs of skin aging. Additional treatments may be necessary to further improve your skin. You may be required to continue with a skin care maintenance program after a treatment.

OTHER - You may be disappointed with the results of your treatment. Infrequently, it is necessary to perform additional treatments to improve your results.

UNKNOWN RISKS - There is the possibility that additional risk factors of treatment may be discovered.

These effects have been fully explained to me (patient’s initials)

(patient’s initials).

Additional Advisories

TRAVEL PLANS - Any treatment holds the risk of complications that may delay healing and delay your return to normal life. Please let the treatment provider know of any travel plans, important commitments already scheduled or planned, or time demands that are important to you, so that appropriate timing of your treatment can occur. There are no guarantees that you will be able to resume all activities in the desired time frame.

TSKIN CANCER/SKIN DISORDERS - Skin treatment procedures do not offer protection against developing skin cancer or skin disorders in the future.

BODY PIERCINGS - Individuals who currently wear body-piercing jewelry in the treated region are advised that an infection could develop from this activity

MENTAL HEALTH DISORDERS AND ELECTIVE PROCEDURES - It is important that all patients seeking to undergo elective treatments have realistic expectations that focus on improvement rather than perfection.
Complications or less than satisfactory results are sometimes unavoidable, may require additional treatments, and can be stressful. Please openly discuss with your treatment provider, prior to the treatment, any history that you may have of significant emotional distress or mental health disorders. Although many individuals may benefit psychologically from the results of elective procedures, effects on mental health cannot be accurately predicted.

PATIENT COMPLIANCE - Follow all pre-and post-instructions carefully; this is essential for the success of your outcome. Post-treatment instructions concerning appropriate restriction of activity, use of post-treatment care and use of sun protection must be followed to avoid potential complications, increased pain, and unsatisfactory results. Your treatment provider may recommend that you utilize a long-term skin care program to enhance results following your treatment.

I certify that I have been fully informed of the nature and purpose of the procedure, expected outcomes and possible complications, and I understand that no guarantee can be given as to the final result obtained. I am fully aware that my condition is of cosmetic concern and that the decision to proceed is based solely on my expressed desire to do so.

I confirm that I have informed the staff regarding any current or past medical condition, disease or medication taken.

I consent to the taking of photographs and authorize their anonymous use for the purposes of medical audit, education and promotion.

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.

Patient Name (Printed)

Witness Name (Printed)

Witness Signature

Date

Patient Intake Forms

Personal Information

Gender
MaleFemale

Skin Type Assessment

Fitzpatrick Skin Type

IIIIIIIVVVI
Ethnicity

Last exposed to UV - (Sun or tanning bed)

Passive tan
YesNo

Self-tanning lotion
YesNo

Hair Assessment

Areas to be treated

Hair density
SparseMediumDense

Hair thickness
FineMediumCoarse

Hair color

Hair density / cm2

Medical History

Pacemaker / defibrillatorMetal implantsCurrent or history of skin cancer / other cancer / pre-malignant molesSevere concurrent medical conditions (e.g. cardiac disorder)Pregnancy and nursingImpaired immune systemDiseases stimulated by light (e.g. Lupus, Porphyria, Epilepsy)Diseases stimulated by heat (e.g. Herpes Simplex)Endocrine disorders (e.g. diabetes. PCO) Surgical ProceduresActive skin infection (e.g. psoriasis, eczema)Skin disorders (e.g. keloids, abnormal wound healing)History of bleeding disordersUse of medication / herbs inducing photosensitivityFacial laser resurfacing / deep chemical peeling, last 3 monthsNeedle epilation, waxing or tweezing, last 6 weeksTattoo or permanent makeupTanned skinSapheneous InsufficiencyInjections/fillers

List any medications taken

List any allergies

Detail any medical condition

Other considerations