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COSMED LASER CENTER

Laser Spider Vein Removal consent 


I understand that the removal or lightening of dilated superficial veins is a procedure that involves using a laser. Some discomfort may be experienced during laser treatment. I understand that there is a possibility of rare side effects such as scarring or permanent discoloration. Other side effects such as swelling, blistering, crusting, or flaking of the treated area, may require one to three weeks to heal. Once any of these conditions have healed, the treated area may still be sensitive to the sun for an additional two to four weeks, or possibly longer in some patients. During the healing process, there is a slight possibility that the treated area can become either lighter (hypo-pigmentation) or darker (hyper-pigmentation) in color compared to the surrounding skin. This is usually a temporary condition; however, on a rare occasion, it can be permanent. It is IMPORTANT that I follow all post-treatment instructions carefully


I understand that if I’ve had sun exposure or used a tanning bed within a 3-day period pre or post treatment I risk a possible pigment change or blistering 


I understand that this procedure involves a laser to coagulate the vessels and a bruising effect could last up to 6 months. It is possible the results will be minimal or not help at all. I realize that each individual’s treatment response is different; therefore it could require multiple treatments to achieve desired results. 


I also understand that once I’ve started my treatment program there are no refunds.


Employee of Cosmed laser center has explained the nature and purpose of the laser vein treatment, including any risks and possible complications, and has discussed the contents of this form with me. I have read and understand this consent form and I agree to its terms and authorize treatment. I further understand that Cosmed laser center cannot guarantee the results and I will not hold Cosmed laser center llc  his/her employees responsible for my individual results of the laser vein treatment that I have requested. 



First Participant's Name

First Name*

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First Participant's Date of Birth*
First Participant's Signature*
Second Participant's Name

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Second Participant's Date of Birth*
Third Participant's Name

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Third Participant's Date of Birth*
Fourth Participant's Name

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Fourth Participant's Date of Birth*
Fifth Participant's Name

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Fifth Participant's Date of Birth*
Sixth Participant's Name

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Sixth Participant's Date of Birth*
Seventh Participant's Name

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Seventh Participant's Date of Birth*
Eighth Participant's Name

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Eighth Participant's Date of Birth*
Ninth Participant's Name

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Ninth Participant's Date of Birth*
Tenth Participant's Name

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Tenth Participant's Date of Birth*
Parent or Guardian's Email Address

Email*

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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.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
 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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