Informed consent for SkinRx + All Facial/Skin Care Treatments This consent form provides the necessary information to assist patients in making an informed decision regarding receiving Skin Care Treatments that include, but are not limited to, Facials, extractions, microdermabrasion, chemical peels and the use of topical skin care products. Microdermabrasion is a mechanical method of removing the outermost layers of the skin through the use of abrasive elements such as a diamond-tipped pad. Chemical peels remove the top layers of the skin through the use of light to mild strength acids. ClearLift™ is a non-ablative approach to laser skin resurfacing. ClearLift providers are able to offer patients skin resurfacing treatments that are fast and virtually painless with visible results* and no downtime. The innovative technology delivers a controlled dermal wound deep beneath the skin, (up to 3mm in depth). The outer layer of the skin is left undamaged. All stages of healing and skin repair occur under the intact epidermis. Alternative treatments to microdermabrasion and chemical peels include laser skin resurfacing, dermabrasion, plastic surgery, or no treatment at all. Our medical facials and peels improve overall skin function and enhance appearance based on the principals of controlled wound. Controlled wounding of the skin helps to stimulate cell renewal and regenerate a healthier epidermis and dermis resulting in firmer, smoother and younger looking skin. These procedures are normally performed within 30-60 minutes depending on the size and area being treated. Please Note: The use of topical vitamin A derivatives (RETIN-A, Retinoids) is contraindicated and must be discontinued 2 weeks before and 2 weeks after treatment.
If you have been prescribed or have taken Accutane within the last 6 months, you may not be able to receive any laser related treatments. Both Accutane and Vitamin A derivatives are direct contraindications and can lead to severe damage. It is recommended that you wait 2 weeks before and after your treatment for any waxing procedures to be completed.
General risks, side effects, and complications with Skin Care Treatments include, but are not limited to: - Prolonged erythema (redness) or edema (swelling)
- Allergic reactions
- Blistering
- Visible flaking/peeling
- Hyperpigmentation or hypopigmentation
- Abrasion (superficial cut) or temporary lines and streaking may occur with micro dermabrasion
- Acne outbreak or the activation of recurrent viral infections such as herpes simplex may occur
- Infection or scarring
The risks of complications are higher for patients with darker skin types. I have disclosed any condition that may have bearing on this procedure such as: pregnancy, recent facial surgery, allergies, tendency to cold sores/fever blisters, or use of topical and/or oral prescription medications such as antibiotics, accutane and/or retinoids.
I understand that the following possible side effect and/or risk could occur: Most people heal without any problems. However, here are some problems that you may encounter: If you are prone to getting fever blisters (herpes simplex) then you might even develop a herpes infection. You will notice that the skin becomes thickened and has a different feel. In fact you should recognize the familiar symptoms of herpes. If so then apply a suitable anti herpetic preparation. You might notice small white dots appearing on the skin. These might be simple little retention cysts (Milia) or they could be minute infected areas. Carefully but firmly wipe them away and apply an antibiotic lotion. It is a good idea to consult your doctor about this. Do not allow the white dots to remain on the skin and if you are not able to remove them yourself then please consult with your doctor. [initial] If the skin becomes painful and redder, then you may have developed an infection and you must see your doctor at once. [initial] I understand that I need to sleep on clean sterile sheets or a clean towel the first 48 hours after treatment to avoid risk of any infection. I understand that it is not possible to predict any of the above side effects or complications, and results are not guaranteed. I have fully read this consent form and understand the information provided to me regarding the proposed procedures, and I have had all questions and concerns answered to my satisfaction. May 7, 2024 STATE MEDICAL SERVICES CONTRACT All Medical treatments are performed by Edmund Fisher MD (Santa Monica) or Noam Rosines (Houston) Inc. dba Lüz Lounge A signed copy of this document is to be emailed/given to the client upon request. Original is to be filed in Client’s medical records. Arbitration Agreement CD0501Y8v2 ARTICLE I: ARBITRATION Article 1.1: Agreement To Arbitrate: It is understood that any dispute as to medical malpractice by Client, including any party that would have standing to assert a claim on behalf of or in connection with services provided to Client, that is as to whether medical services rendered under this contract were unnecessary, unauthorized or lacking informed consent or were improperly, negligently, or incompetently rendered, will be determined by submission to arbitration as provided by State law, and not by a lawsuit or resort to court process except as State law provides for judicial review of arbitration proceedings. For purposes of this agreement, “Dispute” means any claim or controversy of whatever kind or nature including (without limitation) any claim or controversy regarding the formation, validity, interpretation and/or enforceability of this agreement to arbitrate and any claim or controversy by the Client asserting loss of consortium, wrongful death, emotional distress or punitive damages. Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration. Article 1.2: Procedure For Initiating Arbitration: Either party to this agreement may initiate Arbitration by submitting a Demand for Arbitration in writing to the other. The Demand shall contain a plain and simple statement of the nature of the Dispute and the remedy demanded. There shall be one Arbitrator who shall be a retired Judge of a court of record. The Arbitrator shall be selected by agreement of the parties on or before 30-calendar days of the date that the Demand for arbitration is deposited for delivery with a common carrier (as determined by a postmark or other equivalent writing imprinted by the common carrier). If the parties have not agreed to a selection of the Arbitrator, than either party may petition the appropriate Superior Court to appoint the Arbitrator and, consistent with CCP § 1281.6, the Superior Court shall appoint the Arbitrator, who shall have the qualifications stated in this paragraph. Article 1.3: Law Governing Arbitration; Arbitrator’s Award And Enforcement. Without reference to its choice of law rules, the Arbitrator shall apply the substantive law of State. The Arbitrator shall render his or her award in writing and the award shall separately state the Arbitrator’s findings of fact and conclusions of law. The Arbitrator’s award shall be binding on the parties to the arbitration and judgment on the award may be entered by a court of competent jurisdiction. Judicial proceedings to confirm, amend, or vacate the arbitration award shall also take place.. To the extent permitted by law, venue for such proceedings shall be in the county (or the federal judicial district) where the services were rendered. Unless the Arbitrator shall determine otherwise, the Arbitration shall take place in the county where the services were rendered. The Arbitrator shall have the authority to hear any claim and award any remedy that could otherwise be heard or rendered by the Superior Court or a federal district court. Discovery shall proceed in accordance with Code of Civil Procedure, §§ 1283.1, 1282.05, and, in addition, any party, may, of right, bring a motion for summary judgment or adjudication in accordance with CCP § 437c. The parties to this agreement agree to arbitrate in one proceeding all claims arising out of the same or a related incident, transaction or occurrence. Article 1.4: Small Claims Court: Notwithstanding the foregoing any party to this agreement may initiate and prosecute in the small claims division of the Superior Court any claim at law demanding an amount equal to or less than the jurisdictional limit of the small claims division. Notwithstanding applicable law, no judgment in an action initiated in the small claims division may be entered for an amount in excess of the jurisdictional limit of the small claims division. Article 1.5: Severability: If any provision of this arbitration agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provisions. NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY MUTUAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO JURY OR COURT TRIAL. I have read and agree to the terms/conditions listed in this agreement and understand that I have the right to receive a copy of this arbitration agreement upon request. May 7, 2024 | 