532nm Laser 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 laser (532nm), also called a Laser Peel, treatments.
The 532nm laser is used in the treatment of pigmented lesions (such as sun spots and mottled pigmentation) enlarged pores and rough skin texture.
Lasers produce a single wavelength of light. These wavelengths are selectively absorbed by the targets (such as abnormal pigment). 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 and liquid nitrogen for pigmented lesions, or no treatment at all.
Results are affected by many factors including individual skin characteristics and 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 and multiple treatments may be necessary to necessary to achieve maximum benefit.
Immediately after treatment the skin may feel warm or sunburned which typically resolves in 12-24 hours. Pigmented areas get darker and flake off over 1-2 weeks. Gradual pigment lightening may also occur for one month or so after treatment. While this procedure is called a Laser Peel, the skin rarely peels. Freckles or other pigmented spots in the treatment area may be lightened and/or temporarily or permanently disappear.
Test spots may be performed with the laser 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:
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.
Temporary redness and swelling may occur. Cold compresses are recommended to help reduce swelling.
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.
Bleeding and bruising may occur, particularly with tattoo removal treatments. Bruising can also occur with other laser treatments, such as laser hair removal.
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.
Undesired skin texture changes.
Skin fragility or easy bruising following laser treatments.
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.
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.
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.
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.
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.
Inconvenience to the patient during the recovery phase.
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.
Skin is fragile after a 532nm laser treatment. Following skin care instructions and using the recommended products is important for achieving desirable results and reducing the risks of complications.
Consent to laser treatments is also consent to the administration of any related treatments that may be deemed necessary or advisable for the procedures or as a result of the procedure. 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.
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. I understand that photographs shall be part of the medical record and, while primarily used for documentation of response to treatment, may also be used for publication and educational purposes.
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.
532nm Pre & Post Treatment Instructions
Prior to Treatment
Refrain completely from tanning beds and direct sun exposure for 4 weeks prior to each treatment and for the duration of your treatments. Treatments will be cancelled, and the cost of that treatment forfeited if your skin is tanned.
Avoid using sunless tanning products for 2 weeks before treatment.
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 causes photosensitivity (such as: doxycycline and minocycline) for at least 72 hours prior to LASER treatments.
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.
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 customized home skin care products.
After Treatment
Some skin redness and swelling along with a mild to moderate sunburn sensation in the treatment area are common. This may last up to a week.
Tiny red spots (petechiae) or a bruise may be evident after treatment. Petechiae typically resolve in 3-5 days and a bruise can take up to 2 weeks to resolve.
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. A pattern, such as stripes, may be visible on the skin. The lesions and/or skin patterns will gradually darken over the next few days turning brown or even black. They will flake off or fade over 1-2 weeks and this process may take up to 1 month. Do not pick, scratch or remove flaking.
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 Aloe Vera gel or hydrocortisone 1% over-the-counter cream 2 times per day on intact skin up to 5 days to decrease skin irritation.
Gently wash twice daily with a gentle cleanser, do not rub the skin vigorously and avoid hot water, as the skin will be fragile for several days.
Avoid activities that cause flushing for 2-3 days after treatment or as instructed by provider, including: consuming alcohol, exercise, extensive sun or heat exposure; swimming; hot tubs and Jacuzzis.
Avoid irritants such as glycolic and Retin-A products, toners, exfoliants, astringents, or other products that cause irritation for 2 weeks 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 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.
Mineral make-up can be worn immediately after treatment. Non-mineral make-up may be used once there are no signs of skin irritation.
To help ensure the best possible results from treatments and minimize risk of side effects please follow RSMD recommended home skin care products and instructions.
Please contact RSMD Medical Aesthetics at (831) 475-1077 if you have any questions. If problems arise after hours, please contact your nearest urgent care facility