"Informed Consent Form for Treatment(S)"

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Informed Consent for Treatment(s)
Client name:
__________________
Date:
Possible treatment methods: LHR (Laser hair removal), LVR (Laser vein reduction), LFP (Laser facial peel), LCR (Laser cellulite
reduction), IPL (Intense Pulsed Light), LTR (Laser Tattoo removal), Collagen Remodeling/Skin Tightening, Sun spot/Brown spot
removal, Skin tag removal, cherry hemangioma removal, other (please specify) ____________________________________.
Treatment sites: mono-brow, lip, chin, neck, face, ears, arms, fingers, chest, areola, abs, underarms, back, buttocks, bikini, labia, penis,
scrotum, anal, thighs, lower legs, feet, and toes. Please circle all that apply.
The following problems may occur with the above treatments:
1.
There is a risk of scarring.
2.
Short term effects may include reddening, mild burning, temporary bruising or blistering. Hyper-pigmentation
(browning) and Hypo-pigmentation (lightening) have also been noted after treatment. These conditions usually resolve
within 3-6 months, but permanent color change is a rare risk. Avoiding sun exposure before and after the treatment
reduces the risk of color change.
3.
Infection: Although infection following treatment is unusual, bacterial, fungal and viral infections can occur. Herpes simplex
virus infections around the mouth can occur following a treatment. This applies to both individuals with a past history of
herpes simplex virus infections and individuals with no known history of herpes simplex virus infections in the mouth area.
Should any type of skin infection occur, additional treatments or medical antibiotics may be necessary.
4.
Bleeding: Pinpoint bleeding is rare but can occur following treatment procedures. Should bleeding occur, additional
treatment may be necessary.
5.
Allergic Reactions: In rare cases, local allergies to tape, preservatives used in cosmetics or topical preparations have been
reported. Systemic reactions (which are more serious) may result from prescription medicines.
6.
I understand that exposure of my eyes to light could harm my vision. I must keep the eye protection goggles on at all times.
7.
Compliance with the aftercare guidelines is crucial for healing, prevention of scarring, and hyper-pigmentation.
There is also the possibility that other side effects or complications not presently known, recognized, described to you now or
understood may develop now or in the future. A number of side effects, risks, and complications can occasionally be seen. These
include, but not limited to the following complications. Each treatment, you may experience:
Itching on or around area treated
Redness around the follicle
Swelling around the follicle
Tingling or feeling of numbness
The following risks, side effects, and complications are rare, however temporary:
*Purpura (purple bruising)
*Infection (picking area treated)
*Pigment change (hypo, hyper)
*Crusting/scab on ingrown hairs
*New growth of treated hair (depending on previous hair removal methods)
*Failure to improve ‘quality of life’, initial unsightly appearance
*Interruption of daily life, work routine, home/family life or social life
ACKNOWLEDGMENT:
I understand that there are no guarantees and that I am releasing (company name) from all liabilities.
My questions regarding the procedure have been answered satisfactorily.
I understand the procedure and accept the risks.
I hereby release __________________________________________________(individual) and _______________
(company) and Dr._____________________, MD from all liabilities associated with the above indicated procedure.
Client/Guardian Signature __________________________________________________ Date__________________________
Laser Technician Signature __________________________________________________ Date__________________________
Informed Consent for Treatment(s)
Client name:
__________________
Date:
Possible treatment methods: LHR (Laser hair removal), LVR (Laser vein reduction), LFP (Laser facial peel), LCR (Laser cellulite
reduction), IPL (Intense Pulsed Light), LTR (Laser Tattoo removal), Collagen Remodeling/Skin Tightening, Sun spot/Brown spot
removal, Skin tag removal, cherry hemangioma removal, other (please specify) ____________________________________.
Treatment sites: mono-brow, lip, chin, neck, face, ears, arms, fingers, chest, areola, abs, underarms, back, buttocks, bikini, labia, penis,
scrotum, anal, thighs, lower legs, feet, and toes. Please circle all that apply.
The following problems may occur with the above treatments:
1.
There is a risk of scarring.
2.
Short term effects may include reddening, mild burning, temporary bruising or blistering. Hyper-pigmentation
(browning) and Hypo-pigmentation (lightening) have also been noted after treatment. These conditions usually resolve
within 3-6 months, but permanent color change is a rare risk. Avoiding sun exposure before and after the treatment
reduces the risk of color change.
3.
Infection: Although infection following treatment is unusual, bacterial, fungal and viral infections can occur. Herpes simplex
virus infections around the mouth can occur following a treatment. This applies to both individuals with a past history of
herpes simplex virus infections and individuals with no known history of herpes simplex virus infections in the mouth area.
Should any type of skin infection occur, additional treatments or medical antibiotics may be necessary.
4.
Bleeding: Pinpoint bleeding is rare but can occur following treatment procedures. Should bleeding occur, additional
treatment may be necessary.
5.
Allergic Reactions: In rare cases, local allergies to tape, preservatives used in cosmetics or topical preparations have been
reported. Systemic reactions (which are more serious) may result from prescription medicines.
6.
I understand that exposure of my eyes to light could harm my vision. I must keep the eye protection goggles on at all times.
7.
Compliance with the aftercare guidelines is crucial for healing, prevention of scarring, and hyper-pigmentation.
There is also the possibility that other side effects or complications not presently known, recognized, described to you now or
understood may develop now or in the future. A number of side effects, risks, and complications can occasionally be seen. These
include, but not limited to the following complications. Each treatment, you may experience:
Itching on or around area treated
Redness around the follicle
Swelling around the follicle
Tingling or feeling of numbness
The following risks, side effects, and complications are rare, however temporary:
*Purpura (purple bruising)
*Infection (picking area treated)
*Pigment change (hypo, hyper)
*Crusting/scab on ingrown hairs
*New growth of treated hair (depending on previous hair removal methods)
*Failure to improve ‘quality of life’, initial unsightly appearance
*Interruption of daily life, work routine, home/family life or social life
ACKNOWLEDGMENT:
I understand that there are no guarantees and that I am releasing (company name) from all liabilities.
My questions regarding the procedure have been answered satisfactorily.
I understand the procedure and accept the risks.
I hereby release __________________________________________________(individual) and _______________
(company) and Dr._____________________, MD from all liabilities associated with the above indicated procedure.
Client/Guardian Signature __________________________________________________ Date__________________________
Laser Technician Signature __________________________________________________ Date__________________________