CLIENT INFORMATION & MEDICAL HISTORY

In order to provide you with the most appropriate laser treatment, we need you to complete the following questionnaire. All information is strictly confidential.

Step 1 of 2

INFORMED CONSENT FOR REMOVAL/REDUCTION ROSACEA & SPIDER VEINS

Name

Date

I authorize

to perform the procedure. The light pulsed system may dramatically reduce darkly pigmented sunspots and spider veins. More than one laser session may be necessary to achieve desired results. However, other treatments, including skin care products, are often needed to blend color, reduce sun damage, and give the best results. The FDA has given the clearance for removal of brown spots, spider veins, and rosacea. The skin treated will be red and swollen with fine, thin scabs forming. Keep the treated areas covered with Polysporin and Aquaphor until the thin scabs fall off. This process will take anywhere from 1-3 weeks. It could take as long as 3-6 months in some rare cases. Do Not scratch the scabs, as that can cause scarring.

We are unable to treat clients that are on ACCUTANE and PHOTOSENSITIZING medications. Clients using ANTICOAGULANTS should be noted. The following problems may occur with treatment.

Scarring: The light pulsed system can create a bruising and a moderate burn or blister to the skin. For an effective treatment, the power (joules) needs to be below the blistering point which means the skin will be red. There is a risk of scarring.
Hyper-pigmentation (browning) and Hypo-pigmentation (whitening) have been noted after treatment, especially with a darker complexion. This usually resolves within weeks, but it can take as long as 3-6 months in some cases. Permanent color change is a rare risk. If you have a lot of color in your skin, a skin lightening cream will be advised to reduce the melanin in your skin before the treatment. Avoiding sun exposure after the treatment is crucial to reduce the risk of color change.
Infection: Although infection following pulsed light treatment is unusual, bacterial, fungal, and viral infections can occur. Herpes simplex virus infections around the mouth can occur following a laser treatment. This applies to both individuals with a past history of herpes simplex virus infections in the mouth area. Should any type of skin infection occur, additional treatment including antibiotics might be necessary. If you have a history of herpes simplex virus in the treated area we recommend preventative therapy.
Bleeding: Pinpoint bleeding is rare but can occur following brown spot and spider vein treatment procedures. Should bleeding occur, additional treatment might be necessary.
Skin Tissue Pathology: Energy directed at skin lesions may potentially vaporize the lesion. Laboratory examination of the tissue specimen may not be possible. Only clearly benign pigmented lesions can be treated. Check with your doctor for clearance for the treatment.
Allergic reactions: In rare cases, local allergies to tape, preservatives used in cosmetics or topical preparations, have been reported. Systematic reactions (which are more serious) may result from prescription medication. Allergic reactions may require additional treatment.
Wear sunscreen of SPF 25 or higher before and after treatment to protect your skin.
I understand that exposure of my eyes to light could harm my vision. I will keep the eye protection on at all times.
I understand that I may need multiple treatments for the desired outcome.
Compliance with the aftercare guidelines is crucial for healing, prevention of scarring, hyperpigmentation, and hypo-pigmentation.

Occasionally, unforeseen mechanical problems may occur and your appointment may need to be rescheduled. We will make every effort to notify you prior to the arrival in the facility. Please be understanding if we cause you any inconvenience.

AKNOWLEDGEMENT:

My questions regarding the procedure have been answered satisfactorily. I understand the procedure and accept the risks. I hereby release

(Individual) and Amenity Day Spa (Facility) and Dr. Lee (Doctor) from all liabilities associated with the above indicated procedure.

Client/Guardian Signature:

We are unable to treat clients that are on ACCUTANE and PHOTOSENSITIZING medications. Clients using ANTICOAGULANTS should be noted. The following problems may occur with treatment.

Scarring: The light pulsed system can create a bruising and a moderate burn or blister to the skin. For an effective treatment, the power (joules) needs to be below the blistering point which means the skin will be red. There is a risk of scarring.
Hyper-pigmentation (browning) and Hypo-pigmentation (whitening) have been noted after treatment, especially with a darker complexion. This usually resolves within weeks, but it can take as long as 3-6 months in some cases. Permanent color change is a rare risk. If you have a lot of color in your skin, a skin lightening cream will be advised to reduce the melanin in your skin before the treatment. Avoiding sun exposure after the treatment is crucial to reduce the risk of color change.
Infection: Although infection following pulsed light treatment is unusual, bacterial, fungal, and viral infections can occur. Herpes simplex virus infections around the mouth can occur following a laser treatment. This applies to both individuals with a past history of herpes simplex virus infections in the mouth area. Should any type of skin infection occur, additional treatment including antibiotics might be necessary. If you have a history of herpes simplex virus in the treated area we recommend preventative therapy.
Bleeding: Pinpoint bleeding is rare but can occur following brown spot and spider vein treatment procedures. Should bleeding occur, additional treatment might be necessary.
Skin Tissue Pathology: Energy directed at skin lesions may potentially vaporize the lesion. Laboratory examination of the tissue specimen may not be possible. Only clearly benign pigmented lesions can be treated. Check with your doctor for clearance for the treatment.
Allergic reactions: In rare cases, local allergies to tape, preservatives used in cosmetics or topical preparations, have been reported. Systematic reactions (which are more serious) may result from prescription medication. Allergic reactions may require additional treatment.
Wear sunscreen of SPF 25 or higher before and after treatment to protect your skin.
I understand that exposure of my eyes to light could harm my vision. I will keep the eye protection on at all times.
I understand that I may need multiple treatments for the desired outcome.
Compliance with the aftercare guidelines is crucial for healing, prevention of scarring, hyperpigmentation, and hypo-pigmentation.

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Laser Technician Signature:

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