CLIENT CONSENT FORM FOR LASER FACIAL REJUVENATION/ACNE TREATMENT
Iris Beauty Solution appreciates your patronage and interest in Laser /IPL Skin Rejuvenation/Acne Treatment. Please read and fill out this Disclosure and Release form completely, making certain that the address and telephone numbers are correct.
Email: Age: _______ Phone #:
You have the right to be informed so that you may make the decision whether or not to undergo the procedure, after knowing the risks and hazards involved. This disclosure is not meant to frighten you. It is simply an effort to make you better informed so you may give, or withhold, your consent to the procedure.
I hereby authorize and direct certified technicians of Iris Beauty Solution to perform laser facial rejuvenation treatment on me. I understand that after this procedure most clients have no downtime but some people may experience erythema (pinkness or redness) which will be transient. Typically, the redness resolves in one to two hours. Rare individuals may develop inflammatory papules (bumps) or blisters. If these occur these usually resolve in three to four days. An occasional client may develop very slight swelling. This is usually minimal and resolves in 24 hours. The most likely possible complications/risks involved with the proposed procedure and subsequent healing period, including, but not limited to, infection, scarring, crusting or blistering. I also understand that Treatment will not remove deep wrinkles, sagging skin, moderate to deep acne scars; it may improve superficial acne scars, skin texture, pore size, fine wrinkles, blood vessels, red blotches and some pigmentation due to chronic sun damage. Good improvement would be about 25%, outstanding improvement would be 50%. Results vary from individual to individual and cannot be guaranteed. For maximum response, re-treatments are typically done every 3-4 weeks for a total of 4-6 treatments. Improvements to the skin from collagen stimulation can be noted up to six months after the final treatment. Six months after the final treatment maintenance, treatments can be performed as needed. These are usually done several months apart or may not be needed at all. The Laser /IPL should not be used more than 10 min on one area (face) to avoid overheating and burning of the skin.
I hereby that I am not :
• Using photosensitive medicine
• Experiencing serious heart, liver, kidney, other internal organs diseases
• In process of treating cancer
• Intensive Diabetic
• Subject to keloid scaring
I am aware of EYE EXPOSURE - Protective eyewear (shields) will be provided. It is important to keep these shields on at all times during the treatment in order to protect your eyes from accidental laser exposure. I am aware of the following possible experiences/risks with Laser Treatment:
DISCOMFORT - Some discomfort may be experienced during laser treatment.
WOUND HEALING - Laser Treatment can result in swelling, blistering, crusting, or flaking of the treated areas, which may require one to three weeks to heal. Once the surface has healed, it may be pink or sensitive to the sun for an additional two to four weeks, or longer in some patients.
BRUISING/SWELLING/INFECTION - Bruising of the treated area may occur. Additionally, there may be some swelling noted. Finally, skin infection is a possibility although rare, whenever a skin procedure is performed.
PIGMENT CHANGES (Skin Color) - During the healing process, there is a slight possibility that the treated area can become either lighter or darker in color compared to the surrounding skin. This is usually temporary, but, on a rare occasion, it may be permanent.
SCARRING - Scarring is a rare occurrence, but it is a possibility when the skin’s surface is disrupted. To minimize the changes of scarring, it is IMPORTANT that you follow all post-treatment instructions carefully.
EYE EXPOSURE - Protective eyewear (shields) will be provided. It is important to keep these shields on at all times during the treatment in order to protect your eyes from accidental laser exposure.
1. Use sunscreen on a daily basis with an SPF of 29 or higher.
2. The evening of the rejuvenation and the morning after: No scrubbing with a washcloth, no hot water or harsh soap on the face. Use tepid to cool water and be gentle with the skin. Gently blot dry. Be careful if you shower not to let hot water flow over your face. Apply Aloe Vera gel or moisturizing cream to the facial skin in the morning and evening day after treatment.
3. In case of blistering Do not open or pop blisters. Opening the blisters will make the area more vulnerable to infection. Apply a topical hydrocortisone cream and/or antibiotic cream to the burn. Watch the skin for sighs of infection. Once the burns have healed protect the area from sun exposure. Be sure to use an SPF 35 or higher with Zinc Oxide. You can also prevent and treat hyper pigmentation ( dark skin discoloration) by using a 4% Hydroquinone cream and Tretinoin (Retin-A). Topical Serums that contain Vitamin C , and products with growth factors can aid in collagen production, improve skin healing and reduce inflammation.
ACKNOWLEDGMENT: I UNDERSTAND AND ACKNOWLEDGE THAT PAYMENTS FOR THE ABOVE PROCEDURE ARE NONREFUNDABLE. BY MY SIGNATURE BELOW, I CERTIFY THAT I HAVE READ AND FULLY UNDERSTAND THE CONTENTS OF THIS PERMISSION FORM FOR LASER SKIN REJUVENATION TREATMENT AND THAT THE DISCLOSURES REFERRED TO HEREIN WERE MADE TO ME. I agree to indemnify and hold harmless Iris Beauty Solution, its governing officers, consultants, employees, agents, and subsidiaries, from any claim of liability, losses, damages, or any expenses whatsoever as a result of any claims, demands, damages, costs or judgments including, but not limited to, claims based on negligence against it.
Signature-Patient Print Name Date
For any cancellations, you must give 24 hours notice or treatment will be counted as a used treatment.