Intense Pulsed Light Treatment Patient Informed Consent
I _____________________________________________ understand that I am a candidate for pulsed light treatment(s) (hereinafter referred to as the “procedure”). I have reviewed and understand the information given to me and I have discussed all aspects of the specific procedure that I am to receive. The nature of the procedure, the possible complications and risks as well as the possible benefits of the procedure, the alternatives to the procedure and the risks and benefits of those alternatives have been explained to me in a language and in terminology that I understand. Representative staff including the operator/technician who will be performing the procedure and others who represent the organization and may have been engaged in the consultation describing the procedure (hereinafter the “staff") have answered all of my outstanding questions about the procedure. None of the staff have made any promises or warranties or guarantees as to the success or effectiveness of the procedure. The goal of the procedure and the outcome can be influenced by many factors. I understand that 15% if the population does not respond to pulsed light treatments. I also understand that there may be a requirement for more treatments than originally anticipated. I agree to pay the fee quoted and I understand that all fees quoted are non-refundable. I understand that there are numerous risks and complications, both known and unknown, connected to the procedure. Studies and experience with these procedures have included, but are not limited to, these potential complications/side effects; 10 — 20% chance of developing hypo/hyperpigmentation, purpora, bruising, blistering, crusting, freckles and brown spots may lighten and disappear, pimples, redness and swelling, and recent reports have indicated 10% of females being treated in the neck area have documented a slight increase in hair growth. I understand that if I have a history of cold sores or genital herpes I may require pre and post treatment with anti—viral medications. I understand that if I am using topical anesthetics I am solely responsible for their effects in combination with the procedure. Regarding hair reduction pulsed light treatments, I agree that I will not tweeze, wax, thread or have electrolysis done in the area to be treated for four (4) weeks prior to the procedure. I agree I have not been actively tanning or using tanning products for a period of four (4) weeks prior to the first treatment and I agree not to tan or use tanning products at the treatment site while undergoing the series of treatments. I agree to protect my skin with a minimum of a SPF 30 for each four week interval post any procedure at the treatment site.
I understand that the procedure is a relatively new procedure and that minimal data exists concerning its long term safety and effectiveness. I understand that certain medications that I am on which are know to be photosensitizing, will increase my chances of contraindications including pigment changes and blistering. I understand that I will need certain post-care which has been explained to me. If at any time after the procedure I require additional medical attention related to the procedure, I will contact staff within 24 hours of the initial care. I have had the opportunity to ask questions about the procedure and all of my questions have been answered satisfactorily. I understand that in order to achieve the best possible results,
I agree to the treatment intervals staff prescribes for me. I give staff permission to use the data associated with my treatment for research purposes. I understand that my name and personal identifying information will remain confidential, unless I give written permission to disclose this information (client may delete this clause when choosing not to participate in research activities). I am not under the influence of any sedative. I am of clear mind and understand the nature of the procedure and the possible risks related to the procedure. I understand that by signing below, I am indicating that I have read and understood the information in this patient consent form, that I have been verbally advised about the procedure, that I have had an opportunity to ask questions and that I authorize and consent to the performance of this procedure;