PATIENT CONSENT FORM FOR LASER FACIAL REJUVENATION
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
patients have no downtime but some people may experience erythema (pinkness or redness) which wil be transient. Typical y, the redness resolves in one to two hours.
Rare individuals may develop inflammatory papules (bumps) or blisters. If these occur these usual y resolve in three to four days. An occasional patient may develop very
slight swel ing. This is usual y 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 wil 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 typical y 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 usual y done several months apart
or may not be needed at al . The treatment usually lasts up to 10 min on one area (face) to avoid overheating and burning of the skin.
Experiencing serious heart, liver, kidney, other internal organs diseases
Subject to keloid scaring I am aware of EYE EXPOSURE - Protective eyewear (shields) wil be provided. It is important to keep these shields on at al times during the treatment in order to protect your eyes from accidental laser exposure. I am aware of the fol owing possible experiences/risks with Laser Treatment: DISCOMFORT - Some discomfort may be experienced during laser treatment. WOUND HEALING - Laser Treatment can result in swel ing, 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. Additional y, there may be some swel ing noted. Final y, 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 usual y 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 fol ow al post-treatment instructions careful y. EYE EXPOSURE - Protective eyewear (shields) wil be provided. It is important to keep these shields on at al 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 wil 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 col agen 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.
PLEASE NOTE: Do not tan while you are still proceeding with your laser treatments due to risks of burns
and/or scarring. For any cancellations, you must give 24 hours notice or treatment will be counted as a used
MEDICARE NUMBER (and number the child is on it) HEALTHCARE OR Age at diagnosis ______ Year diagnosed ______ accompany child to camp? PARENT/CARER DETAILS SURNAME Diabetes Specialist:________________________________________ General Practitioner:_______________________________________ Diabetes Educator:________________________________________ Dietitian:____________________________________________
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