Laser and Intense Pulsed Light 
General Consent

This consent form is designed to give you the information you need to make an informed decision about whether or not to undergo cosmetic intense pulsed light (IPL) and/or laser (collectively referred to as LASER) treatments.

LASER therapy has been proven to be safe and effective and is approved by the FDA for the treatment of a variety of conditions. LASERs are used in the treatment of: unwanted hair, vascular lesions (including: broken capillaries, redness and flushing and symptoms of rosacea); pigmented lesions (including: sun spots, mottled pigmentation, melasma);enlarged pores, rough skin texture, fine lines and depression scars (acne and chickenpox), skin laxity, active acne, tattoo removal, and other conditions brought about by sun damage and aging. IPL can also be used for bruises to reduce discoloration and speed resolution.

IPL systems produce a broad spectrum of wavelengths and lasers produce a single wavelength of light. These wavelengths are selectively absorbed by the targets (such as abnormal pigment, hair, or small blood vessels). The targets are reduced and the surrounding skin is typically left unaffected.

There are several alternative methods to LASER treatments, including but not limited to: topical skin products, other light-based or LASER systems, liquid nitrogen for pigmented lesions, electrocautery for facial vascular lesions, plastic surgery or no treatment at all.

Results are affected by many factors including individual skin characteristics. Individual response to treatments does vary. No guarantees can be made that a specific patient will benefit from treatment or achieve any level of improvement. Results are cumulative; therefore a series of treatments is often necessary to achieve maximum benefit. In some cases, improvement may not be seen in the treated area for up to six weeks or longer. Certain LASER treatments can show continued improvement for several months after the procedure.

Test spots may be performed with the LASERs prior to treatments. Lack of an adverse reaction with test spots does not ensure that side-effect, adverse reaction or complication will not occur with treatments.

Possible risks, side-effects and complications of LASER treatments include, but are not limited to:
1. Discomfort and pain. This is typically managed without pain medication. Mild to moderate sunburn-like discomfort may occur and last for a few hours to several days.
2. Temporary redness and swelling may occur. Cold compresses are recommended to help reduce swelling.
3. Blistering, burns, and scabbing may also occur, but are rare. Scabs/flaking pigment should not be picked or pulled off and should kept moist with bacitracin ointment.
4. Bleeding and bruising may occur, particularly with tattoo removal treatments. Bruising can also occur with other LASER treatments, such as LASER hair removal.
5. Undesired pigment changes such as hypopigmentation (skin lightening) or hyperpigmentation (skin darkening or discoloration) may occur. While LASER treatments are usually undertaken to lighten areas of unwanted pigmentation, such as melasma or sunspots and improve skin tone and complexion, it is possible to cause darkening of pigmented areas resulting in worsening of skin tone and complexion. These pigment changes typically resolve in three to six months, but in rare cases may be permanent. Use of a full strength sun block (SPF of 30 or greater) after treatment is required to help minimize these risks.
6. Undesired skin texture changes, including but not limited to: enlarged pores especially with radiofrequency microneedling.
7. Skin fragility or easy bruising following LASER treatments.
8. In rare instances, infection can occur. If the area looks infected (honey colored crust, oozing, or spreading/increasing redness), you experience unusual discomfort or bleeding, or your temperature becomes elevated, please call our office immediately.
9. Scarring is rare, but can occur despite proper LASER treatment. It is seen most often in patients with a predisposition to abnormal scarring, such as a history of keloids or other abnormal raised scars.
10. Visible skin patterns. LASER treatment procedures may produce visible patterns within the skin. The occurrence of this is not predictable and is typically temporary but may be permanent.
11. Hair follicles in the treated area may be permanently affected with any LASER treatment, resulting in reduced or no hair growth. Consent to undergo LASER treatments constitutes the acceptance of the possibility of reduced hair growth in the treated areas. Hair follicles can grow at angles to the skin and it is possible to affect hairs adjacent to treatment areas.
12. Risk of accidental eye injury if struck by any LASER beam. Although eye injury is possible, it is unlikely as LASER safety precautions and eye protection are always used throughout all LASER treatments.
13. Inconvenience to the patient during the recovery phase.
14. The risks of LASER use may not be fully known and RSMD, Medical Aesthetics is not responsible for any LASER risk or unforeseen complication not yet discovered or not commonly known.

Patients with darker skin types have an increased risk of complications such as hypopigmentation, hyperpigmentation, blistering, scarring, and more variable results.

Consent to LASER treatments is also consent to the administration of any related treatments that may be deemed necessary or advisable for these procedures. This includes, but is not limited to: local anesthetic such as topical anesthetics (e.g., benzocaine/lidocaine/tetracaine cream or ointment) or injectable anesthetics. Topical anesthetics applied to the skin can be absorbed into the blood. The risks, side effects and complications of anesthetics include, but are not limited to: skin irritation (itching or redness), lightheadedness, rapid heart rate, visual disturbance, tongue numbness. Patients must inform the physician or treating health care provider immediately if experiencing any of these symptoms. There are rare reports of serious complications of lidocaine/anesthetic toxicity including seizures and death. Toxicity may occur when too much anesthetic is administered. Therefore, RSMD, Medical Aesthetics will only use anesthetic medication in the most sensitive areas. Any known allergy to lidocaine or anesthetics must be disclosed to the physician or treating health care provider prior to treatment. The physician or treating healthcare provider must be informed of any inflammation, injury or open skin in the treatment area or any such problems prior to treatments at all visits.

Recurrent viral infections such as herpes simplex (cold sores, genital herpes) or varicella (shingles) may be activated by LASER treatments. The physician or treating health care provider must be notified if you have a history of these conditions prior to treatments and a prescription strength medication may be prescribed to help prevent reactivation or a breakout of these viral infections.

Tattoos and permanent makeup in the treatment area may be altered unintentionally. The physician or treating health care provider must be notified prior to treatment if you have these in or near the treated area and do not want them to be altered.

Patients with the following conditions may not receive LASER treatments: history of abnormal raised scarring or keloid formation; pregnancy or lactation, history of seizures, tanned skin, tanning bed use or active sun exposure four weeks prior to treatment.

Certain conditions require caution with LASER treatments, and may preclude a patient from receiving treatment: poor healing (due to diabetes or other conditions); a personal or family history of skin cancer (such as melanoma); autoimmune disease; use of photosensiting medications (such as doxycycline, minocycline) or a photosensitive disorder (such as Lupus); history of migraine headaches. It is the patient's responsibility to consult with their personal physician prior to having pigmented lesions treated with LASER if they have pigmented lesions that have changed (e.g. enlarged, itched or bled) or if there is a personal or family history of skin cancer. The results of that consultation must be given to RSMD, Medical Aesthetics and the physician or treating health care provider must be notified by the patient of these conditions prior to treatments.

LASER Treatments for Pigmented Lesions
Pigmented lesion response to treatment varies according to the LASER used. With certain LASERS pigmented areas may get darker and flake off over 1-2 weeks. Other LASERS will cause gradual lightening over time, typically one month. Freckles or other pigmented spots in the treatment area may be lightened and/or temporarily or permanently disappear.

LASER Treatments for Vascular Lesions
Vascular lesion response varies according to the LASER used. With certain LASERS vascular lesions may darken and gradually fade over 2-4 weeks or immediately reduce in appearance and become less visible. Bruising, known as purpura, may occur at the vascular lesion site, which typically resolves in 2 weeks, but darkened skin in the bruise area may be permanent.

LASER Treatments for Hair Removal
Alternative methods to LASER treatments for removal of hair include: shaving, plucking, depilatory creams, waxing, electrolysis or no treatment at all. The LASER targets the pigment in hair follicles which damages the follicles and can reduce with hair growth. Individual response to treatments will vary (as it is affected by the nature of hair and the individual skin types, area of treatment and other factors that influence hair growth). In general, most people experience a permanent reduction in the number of hairs following a full course of treatment. However, no guarantees can be made that a specific patient will achieve any level of permanent hair reduction. Six treatments are usually required for lighter skinned patients and 8 treatments or more for darker skinned patients. Male patients may require a higher number of treatments. Immediately after treatment, redness, swelling and a rash (similar to razor burn) are common and may be accompanied by a sunburn-like sensation. These skin changes usually resolve within a few hours to 1 week. Ingrown hairs may occur or worsen temporarily. Folliculitis (infection of the hair follicle) may occur. Treatments may fail to reduce the number of hairs or the diameter (coarseness) of the hairs at the treated site. In rare instances, LASER treatments may stimulate more hair growth. This is called paradoxical hair growth and has been recorded in individuals with darker skin types and finer hair. The physician or health care provider must be notified promptly if you notice more hair in the areas being treated and treatments discontinued. In patients with polycystic ovarian syndrome (PCOS), LASER hair removal may be a maintenance treatment and not permanently reduce hair, due to ongoing hormonal stimulation of hair growth.

Collagen Remodeling with Non-ablative LASER Treatments for Skin Tightening, Wrinkle Reduction, Enlarged Pores, Acne Scars and Rough Texture
Alternative methods to collagen remodeling with non-ablative LASER treatments include, but are not limited to: radiofrequency treatments, ablative laser treatments (such as CO2 and erbium lasers), dermabrasion resurfacing, aggressive chemical peels, plastic surgery, other LASER systems or no treatment at all. It is important to note that the gold standard and best results for excessive skin laxity, crepiness and wrinkles is plastic surgery. Also, non-ablative LASER treatments will not achieve the wrinkle reduction, tightening or smoothing results that can be achieved with ablative or fractional ablative LASER treatments or surgery. Ablative lasers and aggressive operative resurfacing procedures remove layers of skin from the surface down and require prolonged healing time, prolonged redness, and have more risk of side effects and complications. Non-ablative collagen remodeling is a new approach to treatment whereby, stimulation of collagen occurs from inside at the deeper skin layers and the upper skin layers are kept intact.

Infrared (IR) LASERS for tightening of lax and crepey skin do so by soft tissue coagulation. Effects are typically slow, and changes may be seen three to four months after treatment. The degree of improvement ranges from no improvement to modest visual changes. Improvements may occur for 6 months or more after the last treatment. For patients receiving neck IR soft tissue coagulation treatments the following prescreening tests are required before treatments may be started: If you are age 55 or older you are required to have had a carotid ultrasound within the last year, the results of which must be given to RSMD, Medical Aesthetics before starting treatments. If you are age 40 - 55 and have any of the following conditions or a history of these conditions; untreated hypertension, untreated high cholesterol, history of heart attack or known atherosclerotic heart disease, lower leg claudication, smoking or history of stroke; you are required to have had a carotid ultrasound within the last year, the results of which must be given to RSMD, Medical Aesthetics before starting treatments.

I have not had active sun exposure or been in a tanning bed for at least four weeks prior to LASER treatments, or used self-tanning products for at least two weeks prior to LASER treatments.

I have fully disclosed all of my medical history. I understand that it is my responsibility to inform and update RSMD, Medical Aesthetics's physicians and health care providers of any change in my health status and medical history at all visits. All information provided to RSMD, Medical Aesthetics is, to the best of my knowledge, true and correct.

I consent to be photographed. Photographs shall be part of the medical record and may be used for educational purposes and marketing.

I understand that this procedure is considered cosmetic, and is not covered by health insurance. RSMD, Medical Aesthetics will not bill my insurance for this treatment. I understand that my insurance may or may not cover treatment of any complications should they arise. I am responsible for paying the quoted fee for every treatment.

I hereby waive, release, discharge any and all claims and agree to indemnify, defend and hold harmless Dr. Small, the medical staff, specific technician, and RSMD, Medical Aesthetics, its members, employees, and affiliates for any injury, loss, expenses, or damages of any nature which may arise or be alleged as a result of my treatments, including that caused solely or in part by the fault of the above-named parties.

I am an adult of at least 18 years of age. My signature below certifies that I have fully read this consent form and understand the information provided to me regarding the proposed procedure. I have been adequately informed about the procedure including: the potential benefits, limitations, alternative treatments, and I have had all questions and concerns answered to my satisfaction. I understand and accept the risks, side effects and possible complications inherent in undergoing LASER treatments. I consent and authorize Dr. Rebecca Small, a physician assistant, or trained Registered Nurse of RSMD, Medical Aesthetics to perform LASER treatments. This consent shall apply to all subsequent LASER treatments. If I have any questions, problems, reactions or other concerns related to treatments, I will contact RSMD, Medical Aesthetics at (831) 475-1077. If the office is closed or I do not receive a prompt response, I will go to the nearest urgent care facility or emergency room.

I understand that no guarantees or promises can be made or have been made that the condition for which I am seeking treatment will be improved or reduced, and there is a chance that they may be worsened. I also understand that multiple treatments may be required to achieve desired results.

By signing below, I certify that I have fully read and agree to adhere to the pre-treatment and post-treatment instructions with each appointment. I understand that failure to carefully follow these instructions may affect my treatment outcome and increase the likelihood or severity of complications. Any applicable paragraphs were stricken before I signed. I also state that I speak, read and write English.

Laser and Intense Pulsed Light Pre & Post Instructions

Prior to Treatment

• Refrain completely from tanning beds and directsun exposure for 2 weeks prior to each treatment and for the duration of your treatments. Avoid using sunless tanning products for 2 weeks before each treatment. Treatments will be cancelled, and the cost of that treatment will be forfeited if your skin is tan.
  Use SPF 30 or greater sunscreen daily with zinc oxide or titanium dioxide for the duration of your treatments.

• Discontinue use of glycolic and Retin-A containing products 1 week before treatments.

• Do not use medications that cause photosensitivity (such as: doxycycline and minocycline) for at least 72 hours prior to LASER treatments.

• If you have a history of herpes (cold sores) or shingles in the treatment area start your prescribed anti-viral medication (Valtrex, acyclovir) 2 days prior to treatment and continue for 3 days after treatment.

• If possible, come to your appointment with a cleanly washed treatment area. The area must be free of any open sores, lesions or skin infections (e.g., active acne), or treatment may be rescheduled.

• To enhance results of treatment, please inquire with RSMD to obtain home skin care products.

After Treatment

• To help ensure the best possible results from treatments and minimize risk of side effects please follow MBLA recommended home skin care products and instructions.

• Some skin redness and swelling along with a mild to moderate sunburn sensation in the treatment area are common. This should resolve within a few hours but may last up to 3 days.

• Apply a wrapped cool compress or wrapped ice pack to the treated areas for fifteen minutes every 1-2 hours as needed to reduce these symptoms. You may also apply hydrocortisone 1% over-the-counter cream 2 times per day on intact skin up to 3 days to decrease skin irritation.

• Gently wash twice daily with mild soap, do not rub the skin vigorously and avoid hot water, as the skin will be fragile for several days.

• Avoid applying heat to the treated area and activities that can cause flushing for 24 hours after treatment or as instructed by provider including: consuming alcohol, extensive sun or heat exposure, using a hot tub or sauna.

• Light exercise (e.g., walking, gentle yoga) is fine 24 hours after treatment. Avoid strenuous exercise (e.g., Crossfit, hot yoga, hot pilates, running) for 72 hours after treatment.

• Avoid irritants such as glycolic and Retin-A products, toners, exfoliants, astringents, or other products that cause irritation for 1 week following treatment.

• Avoid sun exposure and tanning for 4 weeks following each treatment. Use sunscreen daily with SPF 30 or greater for the duration of your treatments.

• If blistering, crusting or scabbing develops, please call us as soon as possible. Apply a thin layer of antibiotic ointment (such as Bacitracin) to the area twice a day until the skin heals. Do not pick or attempt to remove scabs that form following your treatment, as this may incur infection or scarring. Please call our office if this occurs.

• If significant swelling in the treatment area, take a non-sedating antihistamine daily in the daytime (eg, Zyrtec 10mg, Xyzal .5mg, or Claritin 10mg) and if needed Benadryl 12.5-25mg in the early evening. Please call our office if this occurs.

• Mineral make-up can be worn immediately after treatment. Non mineral make-up may be used once there are no signs of skin irritation
  

Specific Instructions

Treatments for Pigmented Lesions: Prior to treatment of benign pigmented skin lesions, consult your personal physician if there is a family or personal history of skin cancer or if you have skin lesions that have changed in any way, itched or bled recently. Immediately after treatment, pigmented lesions may look raised and/or darker with a reddened perimeter, which may last up to 2 weeks in some cases. The lesion will gradually darken over the next few days turning brown or even black. The lesion will flake off over 1-2 weeks and may take up to 1 month, especially in non-facial areas.  Do not pick, scratch or remove flaking.

Treatments for Vascular Lesions: Immediately after treatment, these may disappear, lighten or change color turning gray or bluish-purple. The lesions will usually lighten over the next week.  You may notice a recurrence of vascular lesions (particularly if you have larger visible blood vessels) commonly two weeks after treatment.  Vascular lesions tend to respond well to treatments spaced at 2-week intervals.

Treatment for Hair Removal: Do not pluck, wax, undergo stringing or electrolysis to desired treatment areas for 4 weeks before LASER hair removal treatments, and do not use depilatory creams or bleach for 2 weeks prior to treatments.  Shave the area to be treated one day prior to your visit.  If the hair in the treatment area is very sparse, please let us shave that area at the time of your treatment. The treatment area must be free of any open sores, lesions or skin infections (e.g., active acne). After treatment, you may notice some singed hairs and hairs that are coming out of the follicle. This is normal and may occur for several weeks. You may gently use a washcloth when washing the area to help remove these hairs.  Do not pick or traumatize the treatment area. Hair that grows in between treatments may appear patchy; this is also normal. Individual response to treatments will vary (as it is affected by the nature of hair and the individual skin types, area of treatment and other factors that influence hair growth). Red bumps or acne-like bumps may occur after treatment. Ingrown hairs may also occur, especially with dark, course, or curly hair. Please call our office if you experience this reaction. In general, most people experience a permanent reduction in the number of hairs following a full course of treatment.  However, no guarantees can be made that a specific patient will achieve any level of permanent hair reduction. Six treatments are usually required for lighter skinned patients and eight treatments or more for darker skinned patients. Results can be optimized by adhering to recommended treatment intervals.

Treatment for Skin Tightening, Wrinkle Reduction, Enlarged Pores, Acne Scars and Rough Texture: After treatment, you may experience deep warmth for a few hours and a sensation of tightening in the treated area. Mild skin redness and occasionally swelling in the treatment area may occur. This should resolve within a few hours but may last up to 3 days.

Please contact RSMD at (831) 475-1077 if you have any questions. If problems arise after hours, please contact your nearest urgent care facility.