Laser Services New Patient Packet Informed Consent for Laser Services This consent form is intended to provide you with the information needed to make an informed decision whether or not to undergo laser therapy treatment for hair removal, pseudofollicular barbae, photorejuvenation, vascular and/or pigmented lesions. Please read this and be sure you understand it completely before making your decision. Laser therapy treatment involves intense light and while it is effective in most cases, there is no guarantee made that a particular patient will benefit from the treatment. Purpose of the Treatment The purpose of this treatment is to reduce and/or eliminate unwanted hair or skin conditions. The Light Sheer Diode is a medical laser that emits a pulse of light that penetrates the skin to a depth of approximately 1mm, Light heats the hair root and causes the hair to shed/fall out within 1-3 weeks after a treatment. Hair grows in 3 growth cycles and is only connected to the hair root during the first cycle, this is why it may take 4-6 treatments to see hair reduction as each hair follicle must be treated twice during the first cycle. In photorejuvenation, the laser heats the water molecules within the skin and triggers collagen to rebuild. With skin lesions, light heats the chromophore within the vascular system destroying the lesion, this may also take several treatments to accomplish. Procedure Most visits last approximately 30 minutes depending on the area treated. During you first visit a Registered Nurse will go over your medical history and examine you suitability for the treatment. During the treatment sessions, the pulsed laser will be applied to the areas of concern and safety and comfort measures will be taken including: ice, cold gel, cooling devices and protective eyewear. Risks, Discomforts, and Complications Clients with freshly tanned or burned skin, using medications which require limited exposure to sunlight or other light (see Photosensitive Med list or ask the front desk), clients suffering from diabetes or bleeding disorders are not permitted to undergo treatment. The most common side effects of this treatment are: Pain Many clients experience some discomfort during the treatment. Clients typically report a very momentary sting on the exposed area. This discomfort may range from minimal to moderate but does not last longer that a few seconds. A mild sun-burn sensation may follow for typically up to one hour and can be reduced with application of cooling and soothing creams Perifollicular erythema/oedema This is swelling or induration around the the hair follicle itself and the severity and duration of the rash depend on the intensity of the treatment and the sensitivity of the area being treated. These phenomena may be reduced with application of cooling and/or inflammatory creams. Superficial wound a crust or blister may occur on the exposed area. It is important not to manipulate or pick which may otherwise lead to scarring. It will heal in 5 to 10 days. Pigmented changes the treatment may heal with changed pigmentation or color. Such a change most often occurs with darker skin or when the area has been exposed to sunlight. It is important to protect the treated area from exposure to sunlight for 3 weeks following treatment. With some client these changes may occur despite adequate protection from sunlight. The change pigmentation, which may include more color (hyper-pigmentation) or less color (hypopigmentation) usually reverts to its original appearance in 3 to 6 months although occasionally a pigment change may be permanent. Scarring there is a small chance of scarring, which could include enlarged scars know as hyper-tropic scars and, very rarely, abnormal heavy raised scar formations called keloid scars. Fragile Skin the skin at or near the treatment area may become fragile. To avoid tearing, this area may not be rubbed or abraded, nor should makeup be applied to the area while this persists. Excessive Swelling Page 1 of 5
immediately after treatment, especially when the treatment involves the cheeks or upper lip, swelling may occur. This condition is temporary, not harmful, and usually subsides in 7 to 10 days if not sooner. Bruising A blue-purple bruise may occur at the treated area. The bruise usually disappears in 5 to 15 days. As it fades a rust discoloration may remain but that usually fades within 1 to 3 months. Please read and initial each statement. Complete, underline or circle individual selection accordingly. I authorize Excellence Medical Group to perform LightSheer INFINITY treatments on me in an effort to improve Hair Reduction / Pseudofolliculitis Barbae / photorejuvenation/vascular or pigmented lesions Other: _ I understand the Risks, Discomforts, and Complications and agree to follow guidelines as stated previously and on the aftercare instructions. I understand that there is a rare possibility of side effects or serious complications including permanent discoloration and scarring. I am aware that careful adherence to all advised instructions will help reduce this possibility. I understand that sun exposure or tanning of any sort may increase the chance for complications. The procedure as well as potential benefits and risks have been thoroughly explained to me and I have had all my related questions answered. Pre and post-care instructions have been discussed and are completely clear to me I understand that results may vary with each individual and acknowledge that it is impossible to predict how I will respond to the treatment and how many sessions will be required I consent to photographs being taken for the purpose of documenting my progress and response to the treatment and be kept solely in my medical record I consent to photographs being used for medical education or publication with my discretion and not revealing my identity (optional) I agree to review the Laser Pre-treatment Questionaire/Compliance Checklist along with my Physician/Nurse Practitioner/Registered Nurse and bring accurate and updated data, to the best of my knowledge Page 2 of 5
Laser Pre-treatment Questionnaire/Compliance Checklist Determining your Fitzpatrick Skin Type: (Circle the column that applies to you) 0 1 2 3 4 What is the natural color Sandy red Blond Chestnut, dark Dark Black of your hair? blond What is the color of sun unexposed skin areas? Reddish Very pale Pale with beige tint Light Dark Do you have freckles on sun exposed areas? Many Several Few Incidental None What happens when you are in the sun TOO long without sunblock? How well do you turn? Do you turn within one day of sun exposure? How does your face respond to the sun? When did you last expose yourself to the sun or artificial sun treatments? Do you expose the area to be treated to the sun? Painful redness, blistering, Hardly or not at all Blistering followed by Light color tan Page 3 of 5 Burns, sometimes followed by Reasonable tan Rarely burns Tan very easily Never had a problem Turn dark very quickly Never Seldom Sometimes Often Always Very sensitive Sensitive Normal Very resistant More than 3 months 2-3 month 1-2 months Less than 1 month Never had a problem Less than 2 weeks Never Hardly ever Sometimes Often Always Total score of all columns circled: Using the table below, circle your skin type according to the total score you calculated above. 00-07 points = Skin type I 17-25 points = Skin type III 30-40 points = Skin type V & VI 08-16 points = Skin type II 25-30 points = Skin type IV Does the skin type determined match the description of you below? Yes/No (circle one) Skin Skin Hair Colour Eye Colour Characteristics Ethnic Group Type Colour I Very fair Blonde Blue/green Never tan, always burn European II Fair Light, Green/hazel Sometimes tan, but European chestnut usually burn III Light olive Chestnut Hazel Usually tan, but sometimes burn European, Hispanic, Darker Caucasian IV Olive Dark Dark Always tan, never burn Asians, Indians, Hispanic, V Dark Brown/black Brown/black Never burn Creole, Hispanic, Mulatto VI Very dark Black Black Never burn Black-skinned, African
Pre-treatment Questions: (Circle the column that applies to you) Any natural or artificial sun exposure in the treatment area in the past 3-4 weeks Use of self tanners or tan enhancer caps within the past 3-4 weeks pre-op plan Use of Photosensitive herbal preparations (St John s Wort, Ginkgo Biloba, etc.), aromatherapy, or essential oils (citrus, peppermint, etc.) Use of steroids or steroid creams YES Use of Antibiotics in the last 2 weeks YES Pregnant or possibility of pregnancy, postpartum or nursing YES Presence or recent history of active cold sores or herpes simplex virus YES Any tattoo and/or dysplastic nevi on requested treatment area that should YES be protected? Previous hair removal procedures on requested treatment area (other IPL/laser, wax, electrolysis, etc ) Within the past 6 weeks? YES Previous skin procedures on requested treatment area (Laser, Botox, fillers, peels, etc...) in the last 4 weeks Medical History/Good Faith Exam: YES YES YES:... YES: what/when?. YES: what/when?. Do you have any allergies (medication, food, lotions, latex, ect.)? Please list Do you have a history of? (circle) Active Skin Disease Anemia Asthma Bleeding Disorder Blood Pressure Problems Bowel Disease Cold sores/ Herpes/Blisters Connective Tissue Disease Deep Dermal Scarring Diabetes Eczema Facial Nerve Palsy Hay Fever Hepatitis A, B, or C Hormonal or endocrine disorders (PCOS/thyroid) Keloid Scarring Liver Disease Metal Implants Myasthenia Gravis Neuropathy Porphyria Psoriasis Seizures Sinus Problems Stomach Ulcers Systemic Lupus Erythematosus Inflammatory skin conditions (dermatitis, active acne, livedo reticularis, erythema ab igne, etc.) Skin cancer Vitiligo Do you have a family member with a history of? (circle) Amyotrophiic Lateral sclerosis Asthma Eczema Facial Nerve Palsy Hay Fever Keloid Scarring Lamvert-Eaton Syndrome Motor neuropathy Myasthenia Gravis Porphyria Sinus Problems Systemic Lupus Erythematosus If yes, please specify who has it Inflammatory skin conditions (dermatitis, active acne, etc.) Skin Cancer List current medications including any medications taken in the last 4 weeks: Do you drink? Yes/No Do you smoke? Yes/No If Yes, how much/often? If Yes, how much/often? Page 4 of 5
What treatments/medications are you interested in having in the future? (circle) Botox/Dysport Chemical Peel Dermal Filler Dermaplaning Foot Detox Hydroquinone IPL Laser Hair Removal Laser Skin Resurfacing Latisse Microdermabrasion Velashape Retin-A Skin Tightening Sclerotherapy Venus Freeze Permanent Cosmetics Spider Veins My signature certifies that I have duly read and understood the content of this Laser Service New Patient Packet and gave the accurate information as to my health condition. I hereby freely consent to LightSheer INFINITY treatments. Name of patient (please print) Signature of patient Date Name of RN (please print) Signature of RN Date Name of Physician/NP (please print) Signature of Physician/NP Date Page 5 of 5