Laser Treatment Consent Form
Please read and initial by each paragraph:
I am 18 years of age or older, or I am accompanied by a parent or legal guardian who will consent for me to have this treatment.
I acknowledge that the laser is a device that produces an intense but gentle burst of light. With this light, there is a minimal amount of risk. These risks (listed below) are typically associated with prolonged exposure to sunlight or use of a prohibited medication.
I understand that the following are possible risks and complications of this procedure including but not limited to:
- Purpura (red-purple discoloration, bruising)
- Itching (hive-like response which lasts 2-3 hours to 2-3 days)
- Herpes simplex virus activation (only if you are already a carrier)
- Burns, blisters, scabbing, crusting, skin color and /or textural changes Hyperpigmentation (darkening of the skin; transient or long term)
- Hypopigmentation (lightening of the skin; transient, long term or possibly permanent) Scarring (rare, possibly permanent)
I understand that my eyes will be covered with laser-specific safety eyewear or an opaque material to protect them from the intense light. My eyes will be closed and I will not attempt to remove the eye protection during treatment.
I understand that complete clearing of my spider veins, brown spots, or redness may not be possible and will depend upon the type, age and color of the trouble spot. Multiple treatments may be needed for the best results.
I understand that other methods of treating this condition will be discussed with me if I request, such that I may assess the risks and benefits of these alternative treatment methods.
I understand I will be given complete instructions regarding after care of the treated area. It is important to follow aftercare instructions carefully to minimize the chance of incomplete healing, skin textural changes or scarring. This includes, but is not limited to, avoiding sun exposure and tanning.
I have answered all questions about medical history and medications honestly and completely.
I understand I will be given the opportunity to ask questions about the procedure and the procedure will be discussed in detail with me.
I have read and understood all information presented to me before signing this consent form.
Date: January 24, 2022