ACKNOWLEDGMENT, WAIVER, AND CONSENT TO RECEIVE LASER PROCEDURES. DO NOT SIGN THIS FORM WITHOUT READING AND UNDERSTANDING ITS CONTENTS. 1. Laser Treatment Informed Consent
- I authorize Bared Monkey Laser Spa Inc to perform laser vein removal procedure on me.
- 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 the results from the treatment vary with each individual. The purpose of this treatment is to attempt to remove, fade, or significantly lighten the veins. This treatment is not a cure for vein disease, nor will it prevent further veins from developing. Multiple treatments may be necessary.
- I understand that tanning over the course of treatments is not recommended and can cause a number of complications. Scheduled treatment may be postponed if the patient is tanned. Tanning and sun exposure should be avoided 2 weeks before and 2 weeks after each treatment. Sunblock with SPF 50 or higher should be used on treated area during the course of laser treatments. It is my responsibility to inform the treatment provider if the skin is darker than when treatment was first started as well as any medical or prescription changes during the course of treatments. Improper post-treatment care may increase the chances of any complications.
- I understand that If I am pregnant/breastfeeding, I am NOT a good candidate for laser.
2. Contraindications You may not be the best candidate for laser veins removal if any of the following contraindications pertain to:
- Pregnancy and nursing
- Use of Accutane (must discontinue use of product 6 months before beginning treatment)
- Use of photosensitive medications (i.e. Anti-biotic, Retinoids or other Acne medications, Antihistamines, Cancer chemotherapy drugs and other cancer drugs, Diabetic drugs, Statins, Malaria medications, Cardiac drugs, St. John Wort etc.) may cause an increased risk of side effects to the laser (must discontinue use of product 4 weeks before beginning treatment)
- Epilepsy or those who have a history of seizures
- Poorly controlled Diabetes
- Current (active) skin cancer within one year or pre-malignant moles in the treatment area. A medical clearance letter is required.
- Active sores or rash (psoriasis, eczema) in the area to be treated
- Skin disorder such as keloids or abnormal wound healing
- History of melanoma, active or inactive anywhere on the body
- Recent (within 1 months) surgery, laser resurfacing or deep chemical peels in the treatment area
- Severe medical disorders such as poorly controlled heart conditions
- Chemo or radiation therapy (letter of clearance from your physician is required)
- Pacemaker, internal defibrillator, and any internal electrical devices
- Any internal metal device, i.e. surgical screws, pins, plates, or implants, in the area to be treated (no treatment if any device is superficially in the body area to be treated)
- Aids, HIV positive or use of immunosuppressive drugs (a letter of clearance from your physician is required)
- Multiple sclerosis ( a letter of clearance from your physician is required with confirmation that the area to be treated is not numb)
- Immune disorders such as Scleroderma, Lupus, Porphyria, Sarcoidosis, and others
- Treatment over moles or lesion of any kind
- Treatment over tattoos, port wine stains, under the eyebrows, or any orifice
- Bleeding problems or use of blood thinners
- History of disease stimulated by heat, such as recurrent Herpes Simplex in the treatment area. You may treat this area only following a prophylactic regime.
3. Risks and Complications All medical and cosmetic procedures are associated with certain risks and may result in complications. Possible risks and complications associated with laser spider vein removal procedure include: • DISCOMFORT: Mild to moderate discomfort is typical during treatment. The treatment settings may be adjusted according to skin reactions and comfort levels • CRUSTING – multiple pinpoint crusts may appear. Antibiotic ointments or healing ointments should be applied. It is important I do not rub nor pick my skin which may otherwise lead to scarring
• RED OR PURPLE SPOTS – broken capillary blood vessels may lead to transient “mini-bruising”. Sun avoidance is essential in that case
• REDNESS/SWELLING/BRUISING – Short term redness (erythema) or swelling (edema) of the treated area is common and may occur. There also may be some bruising. • HYPERPIGMENTATION: (Changes in skin Color): – During the healing process, there is a slight possibility that the treated area may become darker (hyperpigmentation) in color compared to the surrounding skin. This is usually temporary, and it may last one to several months before normal pigmentation levels return. Hyperpigmentation is very rarely permanent. A skin-lightening product may be recommended to accelerate the recovery process. • HYPOPIGMENTATION: (Changes in skin Color): – Lightening or loss of skin pigment is very rare. Transient hypopigmentation lasting several weeks has been reported following crusting/scabbing. Permanent hypopigmentation has not been reported; however, it is a possible adverse event, especially in clients with a history of vitiligo or pigmentary disorders. • BLISTERING: Blisters are not common, but have been reported. If blisters do develop, please contact us immediately for further instruction. • SCARRING – Scarring is a rare occurrence, but it is a possibility whenever the skin's surface is disrupted. Patients with a history of keloid scarring may develop complications and we don't recommend laser spider veins removal treatments.
6. Pre-Procedure Instructions It is IMPORTANT that you follow all pre-treatment and post-treatment instructions carefully to minimize the chances of complications and achieve the optimum results from treatments. 6 months before: 4 weeks before: - Avoid waxing, plucking on the treatment area.
- Avoid photosensitive medications (i.e. Anti-biotic, Doxycycline, Tricyclic antidepressants, Quinidine, Amiodarone, St. John Wort etc.)
- Avoid other laser treatments/ Microdermabrasion/ Chemical Peels/ Botox/ Filler on the treatment site
2 weeks before: - Avoid sun exposure, tanning beds, self tanner such as creams or spray.
- Avoid skin irritants (i.e. Products contain tretinoin, retinol, benzoyl peroxide, glycolic/salicylic acids, astringents, etc.)
- Avoid Anticoagulants
24 hours before: - The area to be treated must be CLEAN SHAVED the day before your treatment.
- If you have a history of Herpes Simplex Virus or cold sores, you must premeditate one day prior to treatment to prevent further outbreaks.
Day of treatment： - Remove any lotions, body oil, perfume, make-up, deodorants and jewelry in the areas to be treated prior to treatment
- Wear loose fitting clothing that will leave the treatment area exposed and easily accessible for treatment. Tight or rough clothing may cause you to feel uncomfortable if the skin becomes sensitive after treatment.
- During your treatment you can expect slight discomfort, similar to a rubber-band snap on your skin. If you have sensitive skin, you may apply a topical numbing cream 30 minutes prior to treatment time in order for it to take effect.
Post-Procedure Instructions Immediately after treatment, there should be erythema (redness) and edema (swelling) at the treatment site which may last several hours to several days. The treated area can feel like a sunburn for several hours after. Please be advised that you may expect a certain degree of discomfort, redness, and/or irritation during and after treatment. If any discomfort or irritation persists, please notify the office. - It is helpful to elevate your legs for the first 48 hours. We also recommend wearing support hose for at least 72 hours after leg vein treatments.
- After your treatment, it is common for the treated veins to remain visible for 3 to 6 weeks before dissipating. This is due to residual clotted blood in the vessel.
- In some rare cases, the treated skin may blister. Do not scratch or open the blister—this could cause permanent scarring and/or infection. If blisters occur, please contact us immediately for further instruction.
- A red scab may form under the skin. It may appear for a few weeks and then will be reabsorbed by the body. This is supposed to happen and is a sign of successful treatment.
- You can expect treated areas to remain somewhat red and swollen for the first 24 to 48 hours. In some cases, this may last up to 1 week.
- It is possible to have pain from the treatment of larger veins for several days post-treatment. Tylenol and/or arnica are recommended for any discomfort.
- Do NOT engage in vigorous aerobic activity such as running, hiking, or aerobic exercise for approximately 72 hours post-treatment.
- It is advised to remain out of the sun for a minimum of 2 week. It is recommended that you use a 50 SPF sunblock for any sun exposure.
- The skin of the treated areas may tend to itch. This is a sign of healing. Keep areas hydrated with moisturizer and apply hydrocortisone cream to itchy areas 3-4 times daily until itchiness subsides.
- Bruising is another common side effect of laser treatment. Bruising is temporary and will dissipate within a matter of days or weeks depending on your individual healing process. Arnica is recommended if you have a tendency to bruise. Arnica helps reduce bruising and eases the soreness of bruising.
- Blisters are not common, but have been reported. If blisters do develop, please contact us immediately for further instruction.
By signing below, I certify all information is true and correct to the best of my knowledge: - I certify that the information contained in this Informed Consent was explained to me using terms I could understand, and all my questions and concerns have been answered. After reviewing all the information provided to me about cosmetic procedures and reviewing my health status, I believe I am a good candidate for Laser Veins Removal procedure.
- I understand that I am not allowed to have laser veins removal treatments without a written approval from a parent and/or legal guardian if I am under 18 years old.
- I understand it's my sole responsibility to inform my technician about any changes in my current medical conditions prior to any of my laser treatments.
- I acknowledge and accept the risks inherent in the Laser Veins Removal Procedures. I voluntarily assume the risk of possible complications and side effects which may arise from the Laser Treatments set forth herein; and any of my heirs, executors, representatives or assigns hereby release Bared Monkey Laser Spa and all its affiliated companies from any and all claims, liabilities for personal injury, and property damages of any kind sustained while on the premises, during the treatments set forth herein by any employees or representatives of Bared Monkey Laser Spa and all its affiliated companies.
- I certify that I have been informed of the nature and purpose of the procedure, expected outcomes and possible complications, and I understand that no guarantee can be given to the final result obtained. I am fully aware that my condition is of cosmetic concern and that the decision of to proceed is based solely on my expressed desire to do so.
- I certify that I am not pregnant and I am not planning to get pregnant during the course of the treatment.
- I certify that I have not taken Accutane within the past six months.
- I certify that I have not taken Anti-biotic within the past four weeks.
- I certify that I do not have a pacemaker or internal defibrillator.
- I confirm that I have read the pre-treatment and post-treatment instructions provided by Bared Monkey Laser Spa and all its affiliated companies and I understand that it's my responsibility to follow these instructions and that my failure to adhere to these recommendations may result in complications and contraindications for which I am fully responsible.
- I agree to receive text messages and emails from our appointment confirmation and promotional text message or email will be delivered to the phone number and email on this waiver. You can reply Stop to opt-out text message and/or click on unsubscribed in any email to cancel email communication.
- I certify that I have read the entire above Informed Consent and believe the Bared Monkey Laser Spa and all its affiliated companies has adequately explained the risks of this therapy, alternative methods of treatment, and possible benefits from this treatment, and I hereby consent to the laser treatment to be performed by the technicians of Bared Monkey Laser Spa and all its affiliated companies. Considering that I have been informed that certain medical conditions and medications prohibit the patient from laser therapy, I have provided a full and truthful medical history and a truthful and accurate account of my medications to this office. Having been apprised of all the above, I have signed this Consent Form and authorize the subject treatment.
December 4, 2024
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