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LUXURY BROW + SKIN CLIENT CO2 LASER TREATMENT CONSENT FORM AND WAIVER

This is an informed-consent document which has been prepared to help inform you about resurfacing procedures of the skin, including alternative treatments and risks.

It is important that you read this information carefully and completely. Please read each page and sign the consent for your CO2 laser procedure as proposed by your laser technician. A CARBON DIOXIDE LASER treatment is used for skin resurfacing. Thin layers of skin are vaporized using a high-energy beam of laser light. This creates a “controlled injury” to the skin: as the skin heals, it produces collagen as a natural part of the healing process, which restores your skin’s elasticity. CO2 laser resurfacing is designed to minimize wrinkles, reduce facial scarring, even out skin tone, and increase dermal collagen.

ALTERNATIVE TREATMENT

Alternative forms of treatment include not undergoing the proposed skin resurfacing procedure. Other forms of management include chemical peels, dermabrasion, or surgical procedures, such as excisional surgery. In certain situations, the laser may offer a specific therapeutic advantage over other forms of treatment. Alternatively, laser resurfacing procedures may not represent a better alternative to other forms of surgery or skin treatment when indicated. Risks and potential complications are associated with alternative forms of treatment that involve skin resurfacing(s) or surgical procedures.

RISKS OF LASER RESURFACING ARE AS FOLLOWS:

Every procedure involves a certain amount of risk, and it is important that you understand the risks involved. An individual’s choice to undergo a procedure is based on the comparison of the potential risks to benefits. Although most patients do not experience the following complications, you should discuss each of them with your plastic surgeon(s) to make sure you understand the risks, potential complications, and consequences of laser resurfacing treatment.

INFECTION - Although infection following skin treatment is unusual, bacterial, fungal, and viral infections can occur. Herpes simplex virus infections around the mouth, can occur following a resurfacing treatment. This applies to both individuals with a past history of Herpes simplex virus infections and individuals with no known history of Herpes simplex virus infections in the mouth area. It is advised to contact your family practice doctor prior to treatment if prescription meds, such as Valtrex (antiviral), are needed. to be taken prior to treatment to suppress a potential infection from this virus. Should any type of skin infection occur, additional treatment including antibiotics may be necessary.

SCARRING - Although normal healing after the procedure is expected, abnormal scars may occur both in the skin and deeper tissues. In rare cases, keloid scars may result. Scars may be unattractive and of different color than the surrounding skin. Additional treatments may be needed to treat scarring.

BURNS- Laser energy can produce burns. Adjacent structures including the eyes may be injured or permanently damaged by the laser beam. Burns are rare; if a burn does occur, additional treatment may be necessary to treat laser burns.

BLISTERS - It is common for treated areas to develop blisters. It is important to keep skin clean and moist during this time.

PEELING- It is common for treated areas to peel. Once skin begins to peel it will generally turn dark. Do not pick at skin; It is important to allow skin to heal on its own.

COLOR CHANGE - Resurfacing may potentially change the natural color of your skin. Skin redness usually lasts 1-3 months and occasionally 6 months following laser skin resurfacing. There is the possibility of irregular color variations within the skin including areas that are both lighter and darker. A line of demarcation between normal skin and treated skin can occur.

ACCUTANE (isotretinoin) - Accutane is a prescription medication used to treat certain skin diseases. This drug may impair the ability of skin to heal following treatments or surgery for a variable amount of time even after the patient has ceased taking it. Individuals who have taken this drug are advised to allow their skin at least 6 months to recover from Accutane before undergoing skin treatment procedures.

BLEEDING – depending upon the depth of treatment, pinpoint bleeding is common.

SKIN TISSUE PATHOLOGY - Laser energy directed at skin lesions may potentially vaporize the lesion. Laboratory examination of the tissue specimen may not be possible.

VISIBLE SKIN PATTERNS - Treatment procedures may produce visible patterns within the skin. The occurrence of this is not predictable.

PAIN - Very infrequently, chronic pain may occur after skin resurfacing procedures.

DELAYED HEALING - It may take longer than anticipated for healing to occur after treatments. Skin healing may result in thin, easily injured skin. This is different from the normal redness in skin after a treatment. It is important to follow the post treatment guidelines given to you to insure optimal healing. Smokers have a greater risk of skin loss and wound healing complications.

ALLERGIC REACTIONS - In rare cases, local allergies to tape, preservatives used in cosmetics or topical preparations have been reported. Systemic reactions which are more serious may result from drugs used during surgery and prescription medicines. Allergic reactions may require additional treatment.

DAMAGED SKIN - Skin that has been previously treated with chemical peels, lasers, or dermabrasion, or damaged by burns, electrolysis (hair removal treatments), or radiation therapy may heal abnormally or slowly following treatment by lasers or other surgical techniques. The occurrence of this is not predictable. Additional treatment may be necessary.

SKIN CANCER/SKIN DISORDERS - Skin resurfacing procedures may not offer protection against developing skin cancer or skin disorders in the future.

DISTORTION OF ANATOMIC FEATURES - Skin treatments can produce distortion of the appearance of the eyelids, mouth, and other visible anatomic landmarks. The occurrence of this is not predictable. Should this occur, additional treatment including surgery may be necessary.

PATIENT FAILURE TO FOLLOW POST TREATMENT GUIDELINES – Following post treatment guidelines after a skin resurfacing procedure is important. Guidelines concerning appropriate restriction of activity, use of dressings, and use of sun protection need to be followed to avoid potential complications, increased pain, and unsatisfactory results. It may be recommended that you utilize a long-term skin care program to enhance healing following a skin resurfacing.

UNSATISFACTORY RESULT - There is the possibility of an unsatisfactory result from these procedures. Resurfacing procedures may result in visible deformities, skin slough, loss of function, and permanent color changes in the skin. You may be disappointed with the final result from laser resurfacing.

LACK OF PERMANENT RESULTS - Resurfacing treatments may not completely improve or prevent future skin disorders, lesions, or wrinkles. No technique can reverse the signs of skin aging. Additional surgical procedures may be necessary to further tighten loose skin.

UNKNOWN RISKS - There is the possibility that additional risk factors of laser skin resurfacing may be discovered. The results of performing skin tightening surgery and resurfacing are unknown in terms of the combination effect of the two procedures and potential complications, depending on the area treated. Skin slough, delayed healing and poor surgical outcome may occur.

FIRE - Inflammable agents, surgical drapes and tubing, hair, and clothing may be ignited by laser energy. Laser energy used in the presence of supplemental oxygen increases the potential hazard of fire. Some anesthetic gases may support combustion.

LASER SMOKE (plume) - Laser smoke is noxious to those who encounter it. This smoke may represent a possible biohazard.

ADDITIONAL TREATMENT OR SURGERY NECESSARY

There are many variable conditions which influence the long-term result of laser skin treatments. Even though risks and complications occur infrequently, the risks cited are the ones that are particularly associated with these procedures. Other complications and risks can occur but are even more uncommon. Should complications occur, additional treatments may be necessary. Although good results are expected, there is no guarantee or warranty expressed or implied on the results that may be obtained.

FINANCIAL RESPONSIBILITIES

The cost of the service is to be paid in full at the time of the service.

DISCLAIMER

Informed consent documents are used to communicate information about the proposed treatment of a condition along with disclosure of risks and alternative forms of treatment(s). The informed consent process attempts to define principles of risk disclosure that should generally meet the needs of most patients in most circumstances.

However, informed consent documents should not be considered all-inclusive in defining other methods of care and risks encountered.

Informed consent documents are not intended to define or serve as the standard of medical care. Standards of medical care are determined based on all the facts involved in an individual case and are subject to change as scientific knowledge and technology advance and as practice patterns evolve.

It is important that you read the above information carefully and have all your questions answered before signing the consent.

CONSENT FOR CO2 PROCEDURE

1. I hereby authorize Dazx McLoughlin, and such assistants as may be selected, to perform laser skin resurfacing.

I have received and read the following information sheets:

• CONSENT FOR CO2 LASER TREATMENT

• CO2 PRE-TREATMENT GUIDELINES

• CO2 POST-TREATMENT GUIDELINES

2. I recognize that during the medical treatment, unforeseen conditions may necessitate different procedures than those above. I therefore authorize the above physician(s) and assistants or designees to perform such other procedures that are in the exercise of his or her professional judgment necessary and desirable. The authority granted under this paragraph shall include all conditions that require treatment and are not known to my physician(s) at the time the procedure is begun.

3. I consent to the administration of such anesthetics considered necessary or advisable. I understand that all forms of anesthesia involve risks, and the possibility of complications, or injury.

4. I acknowledge that no guarantee has been given by anyone as to the results that may be obtained.

5. I consent to the photographing and video recording of the or procedure(s) to be performed, including appropriate portions of my body, for medical, scientific or educational purposes, provided my identity is not revealed by the pictures.

6. IT HAS BEEN EXPLAINED TO ME IN A WAY THAT I UNDERSTAND:

a. THE ABOVE TREATMENT OR PROCEDURE TO BE UNDERTAKEN

b. THERE MAY BE ALTERNATIVE PROCEDURES OR METHODS OF TREATMENT.

c. THERE ARE RISKS TO THE PROCEDURE OR TREATMENT PROPOSED

I CONSENT TO THE TREATMENT OR PROCEDURE AND THE ABOVE LISTED ITEMS (1-6). I AM SATISFIED WITH THE EXPLANATION.

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Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
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 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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