Informed Consent For Facial Rejuvenation/Collagen Remodel Client s name: Date: I authorize SilkySkin Laser Centers to perform the laser procedure. You will be treated with the Cynosure Elite TM laser, which is used for dermatological procedures requiring soft tissue coagulation. More than one laser session may be necessary to achieve desired results. 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: Pain - Some people may feel some pain with this treatment, similar to snapping the skin with a rubber band. Reddening Laser treatment will cause a reddening of the area. The reddening will go away in one to two weeks. Swelling Laser treatment may cause swelling, which will usually go away in one week or less. Pigment Changes Although extremely rare, the treated area may heal with increased pigmentation (increased skin coloring). This occurs most often with darker colored skin and after exposure of the area to sun. You may have experienced this type of reaction before and noticed it with minor cuts or abrasions. The treated area must be protected from exposure to the sun (sunscreen for 4 weeks after treatment) to minimize the changes of too much pigmentation (increased skin coloring). However, in some subjects, increased skin coloring may occur even if the area has been protected from the sun. These spots usually fade in three to six months. In some cases, the pigment change is permanent. In some subjects who experience pigment alteration, the treated area loses pigmentation and becomes a lighter color than the surrounding skin. This type of reaction tends to gradually fade away and return to normal over a period of three to six months. Scarring There is a small chance of skin scarring, including abnormal raised scars. Scarring is a possibility because of the disruption of the skin s surface. Compliance with aftercare is crucial for the prevention of scarring.
Bleeding The laser treatment may cause some pinpoint bleeding which will probably stop within a few minutes without any lasting effect. The bleeding may not reach the upper level of the skin and may result in a dark reddening of the skin. The red color will darken to purple and purple-yellow and will disappear in one to two weeks. Blistering The laser procedure may produce heating in the upper layers of the skin resulting in blister formation. The blisters will go away within two to four days. Scabbing A scab may be present after a blister forms. The scabbing will disappear during the natural wound healing process of the skin. Infection If a blister or bleeding is present, an infection of the wound is possible. Any blistering or bleeding must be dressed with an antibiotic ointment and covered. An infection could last seven to ten days and could lead to scarring. It is important to follow all post-treatment instructions carefully. ACKNOWLEDGMENT: My questions regarding the procedure have been answered satisfactorily. I understand the procedure and accept the risks. I Consent to the taking of photographs during the course of my laser therapy for the purpose of medical education. These photographs may be used for teaching or publication, as the case provider deems appropriate with a full respect to compete personal identity confidentiality. By putting my initial here AND my date of birth I do acknowledge that I do NOT want my photographs to be published, but it will be kept in my personal file for medical use only. -Initial -Date of birth: / / I hereby release Norma Khal, George Allen, MD and Silky Skin Laser Centers from all liabilities associated with the above indicated procedure. Client/Guardian Signature Laser Technician Signature Date Date
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. PERSONAL HISTORY Client Name Today s Date Date of Birth Age Occupation E mail: Home Address City State Zip Code Home Phone: ( ) - Cell ( ) - Work Phone ( ) - Emergency Contact Name and Phone How were you referred to us? Which of the following BEST describes your skin type? (Please circle ONE skin type) Type I Always burns, never tans, light color hair and eyes Type II Usually burns, tans with difficulty, light skin, light colored hair Type III Sometimes burns, but usually tans, darker eyes, slight coloring to the skin Type IV Rarely burns, tans easily, dark eye color, definitive darkening skin color Type V Very rarely burns, dark hair and eye color Type VI Very dark skin color, dark coarse hair, dark eyes Do you regularly use tanning salons or sun bathe? If yes; how often? Have you had any recent tanning or Yes sun exposure that changed the color of your skin? No Have you recently used any self-tanning lotions or treatments? Yes No Do you form thick or raised scars from cuts or burns? Yes No Do you have Hyper pigmentation (darkening of the skin) or Hypo pigmentation (lightening of the skin) or marks after physical trauma? Yes No If yes, please describe: * ONLY answer these questions if you are interested in laser hair removal Have you ever had laser hair removal? Yes No Have you used any of the following hair removal methods in the past six weeks? Shaving Waxing Electrolysis Plucking Tweezing Stringing Depilatories Method Area(s) Method Area(s) Shaving Depilatories Tweezing Electrolysis Waxing Laser Other: Other:
MEDICAL HISTORY Are you currently under the care of a physician? If yes, for what: Yes No Are you currently under the care of a dermatologist? Yes No If yes, for what: Do you have a history of erythema abigne, which is a persistent skin rash produced by prolonged or repeated exposure to moderately intense heat or infrared irritation? Yes No Do you have any of the following medical conditions? (Please check all that apply) Cancer Diabetes High blood pressure Herpes Arthritis Frequent cold sores HIV/AIDS Keloid scarring Skin disease/skin lesions Seizure disorder Hepatitis Hormone imbalance Thyroid imbalance Blood clotting abnormalities Any active infection Do you have any other health problems or medical conditions? Please list: Have you ever had an allergic reaction to any of the following? (Please check all that apply and describe the reaction you experienced) Food Latex Aspirin Lidocaine Hydrocortisone Hydroquinone or skin bleaching agents Others: MEDICATIONS What oral medications are you presently taking? Birth control pills Hormones Others (Please list): Are you on any mood altering or anti-depression medication? Have you ever used Accutane? Yes No, If yes, when did you last use it? What topical medications or creams are you currently using? Retin-A Others (Please list): What herbal supplements do you use regularly? Female client: Are you pregnant or trying to become pregnant? Yes No Are you breastfeeding? Yes No Are you using contraception? Yes No I certify that the preceding medical, personal and skin history statements are true and correct. I am aware that it is my responsibility to inform the technician, esthetician, therapist, doctor or nurse of my current medical or health conditions and to update this history. A current medical history is essential for the caregiver to execute appropriate treatment procedures. Signature Date:
ERUBIUM AND ABLATIVE LASERS SKIN RESURFACING/AFTER CARE FORM The treated area is extremely delicate and must be handled with care during the initial healing phase (7-10 days). It may take a few weeks after bruising or scabs to disappear for you to notice fading of your lesions. Your response to treatment, therefore, will not be evaluated for several weeks, when the healing process is complete. 1. Apply Bacitracin, Polysporin, or Betamethasone ointment (not Neosporin). It is normal for the treated area to feel like sunburn for a few hours. You should use a cold compress wrapped in a soft cloth if needed. For 10-15 minutes each hour for 4 hours. Avoid any trauma to the skin. Showers are permitted, but prolonged bathing is not advised. Gently pat dry with a soft cloth. Do not rub with a towel or washcloth because the area is extremely delicate while healing. Avoid strenuous exercise, or massage. 2. Avoid picking or pop any blisters, on the treated skin to achieve your best results. If any crusting, apply antibiotic cream. Some physicians recommend aloe vera gel or some other after sunburn treatment such as Desitin. Darker pigmented people may have more discomfort than lighter skin people and may require the aloe vera gel or an antibiotic ointment longer. Follow instructions as specified by your laser professional. 3. Makeup may be used after the treatment has quit swelling unless there is epidermal bleeding. It is recommended to use new makeup to reduce the possibility of infection. Keep the area moist. Any moisturizer without alpha-hydroxy acids will work. 4. Do not tan the laser-treated area 5. You will experience redness and bruising from five to fourteen days at the treatment. Avoid direct sun exposure and tanning beds for 1-2 months and throughout the course of the treatment so as to reduce the chance of dark or light spots. Use sunscreen SPF 25 or higher at all times throughout the treatment when going outside. 6. Avoid tweezing, waxing, bleaching or chemical peels during the course of the treatment. Do not use any irritants such as Retin-A, Benzoyl Peroxide or astringents. 7. If work on the leg has been done, wear compression stockings for 48 hours and then during the day while on feet for up to two weeks. 8. Call your physician s office with any questions or concerns you have after the treatment.