Skin Care Treatments Consent
This consent form is designed to give you the information you need to make an informed decision about whether to undergo Skin Care Treatments (“Treatments"). Skin Care Treatments include but are not limited to: superficial mechanical exfoliation (dermaplaning and microdermabrasion); chemical exfoliation (chemical peels and enzymes); puncture of lesions such as milia (also called lancing); waxing and use of skin care products.
These Treatments stimulate the skin to renew and generate new skin cells, collagen, increase blood circulation to the skin, and help the skin to absorb active ingredients during treatment and in home care products. For visible improvement in the appearance and health of your skin, one Treatment rarely results in optimal results and multiple Treatments along with an office prescribed topical skin care program for home use are typically necessary to achieve optimal results. If you have any questions, please ask Dr. Small or other health care professional from the office of Dr. Rebecca Small, A Medical Corporation (RSMD).
Mechanical and Chemical Exfoliation
Mechanical exfoliation (ME) is a physical method of skin exfoliation of the top layers skin, which involves removing the outermost layer of the skin either by: dermaplaning, with the use of a special scalpel blade or microdermabrasion, with the use of elements such as; abrasive crystals, bristles, diamond-tipped heads and other materials. ME is a superficial and may result in smoothing of the skin and assist with reduction of unwanted skin pigmentation. ME may also result in the removal of the facial hair from the area treated, particularly with dermaplaning. I understand that the color, texture, and amount of facial hair are determined by hormonal activity. I understand that shaving will not cause an increase in hair growth, but facial hair may feel coarser and appear darker after Treatment. A prescription medication may be used to help reduce unwanted fine, light colored facial hair from recurring after Treatment, please inquire with the physician if desired.
Chemical exfoliation (CE) involves exfoliating the top layers of skin through use of acids, including but not limited to: glycolic, salicylic, trichloroacetic acid, retinoic acid; and/or enzymes, including but not limited to bromelain and papain; and may be mixed with other ingredients including but not limited to kojic and ascorbic acid. A patch test with one or more of the above products may be performed prior to Treatment to help assess the skin's response to products. Lack of an adverse reaction with a test patch does not ensure that a side-effect, adverse reaction or complication will not occur with any Treatment.
Alternative treatments to ME and CE include but are not limited to: ablative and non-ablative laser skin resurfacing, plastic surgery or no treatment at all.
Prior to Treatment
Refrain completely from tanning and direct sun exposure for two weeks prior to each Treatment and after each Treatment for 4 weeks. Exfoliating products such as alpha-hydroxy acids (e.g., glycolic, lactic) or retinoic acid products (e.g., Retin-A, Renova, Differin) are to be discontinued two weeks prior to all Treatments. The treatment area must be free of any open sores, lesions, or skin infections. It is your responsibility to have any skin lesions in the treatment area which have changed in any way, itched or bled, evaluated by your regular physician prior to starting Treatments. Avoid waxing in the treatment area two weeks prior to treatment.
During Treatment
The skin may feel warm, tingle, sting or burn. These sensations will subside during the Treatment. Patient feedback is important in performing Treatments properly and for optimum results. Please inform the skin care specialist if these sensations are too intense or prolonged for you at the time of Treatment.
After Treatment
Immediately after your procedure, the skin may feel sensitive, tight, itchy, dry and appear pink, red and slightly swollen for 3-5 days. The degree of skin peeling from chemical exfoliation Treatments will vary (from mild to heavy continuous peeling) and is dependent on the Treatment received. Lack of peeling does not indicate that the Treatment was ineffective or too weak. Do not pick, abrade, pull, forcibly remove or scrub skin that is sensitive or peeling. This may cause surface scarring, irritation and interrupt the skin's natural rejuvenation process. After Treatment, follow the home skin care program recommended by your skin care specialist to keep your skin moist and hydrated. While skin is peeling, avoid sweating excessively, use of steam, sauna and hot water on the face. Direct sun exposure and tanning should be avoided for four to six weeks following Treatment and a broad-spectrum sunblock (SPF 30 or higher with zinc or titanium) should be applied daily to treated areas.
Waxing
Immediately after hair is removed with wax you may experience: skin redness, irritation, minimal swelling and pain in the treated area that typically subsides within a few hours. A rash with small red bumps may occur at the treated hair follicles, which usually resolves within three days.
Patients with the following conditions may not receive Skin Care Treatments: abnormal scarring or keloid formation, Accutane use in the last 6 months, currently pregnant or nursing, active skin infection in the treatment area, known allergy to any ingredient in used in Treatments. Certain conditions require caution with Treatments and may preclude a patient from receiving Treatment: poor healing (due to uncontrolled diabetes, chemotherapy, radiation therapy or other conditions), conditions or use of oral medications that weaken the immune system (e.g., uncontrolled diabetes, active cancer, chemotherapy), smoking or vaping, aspirin allergy, long-term use of prednisone or other steroid therapy, sunburned skin or recent sun exposure with tanned skin. The RSMD health care provider you are seeing must be notified of these conditions prior to Treatment at each visit.
Treatments should be performed at least one day after Botulinum Toxin; at least one week after dermal filler injections, intense pulsed light, laser hair reduction, depilatory cream use (e.g., Neet), electrolysis; ME and CE Treatments; and at least two weeks after non-ablative laser skin resurfacing.
Possible risks, side-effects and complications with Skin Care Treatments include, but are not limited to:
Discomfort or pain during and after Treatments in the treated areas. This generally, lessens and resolves within 24 hours after Treatments and typically does not require pain medication.
Redness and swelling. These reactions are usually present immediately after Treatment and lessen or disappear within a few days to 1 week. Occasionally, prolonged redness may occur, sometimes lasting up to a month.
Pigment changes. Rarely, there may be a worsening of hyperpigmentation (dark or discolored) with Treatments. Other pigment changes that may occur include: hypopigmentation (skin lightening), blotchiness or uneven pigmentation. Pigment changes usually resolve in three to six months but may be permanent. Post-treatment use of a full strength (SPF of 30 or greater with zinc or titanium) sunblock daily is required to help minimize this risk. Patients with darker skin types have an increased risk of complications such as hypopigmentation, hyperpigmentation and scarring.
Recurrent viral infections such as herpes simplex (cold sores) or varicella (shingles) may be activated by Treatments. I understand that it is my responsibility to inform the physician of these conditions prior to my Treatment as a prescription may be required.
Abrasions (superficial excoriations), temporary lines, and streaking may occur. In addition; lacerations (cuts) or nicks, may occur with dermaplaning.
Acne outbreak.
Allergic reaction to facial products and make-up used may occur with redness, itchiness and, in rare instances, chemical burns and blistering.
Infection in the treated area. Any time the skin barrier is broken there is risk of infection, such as bacterial or fungal. Viral infection is also possible such as reactivation of herpes. Oral and or topical medications may be necessary for treatment.
Scarring is rare but can occur. It is seen most often in patients with a predisposition to abnormal scarring, such as a history of keloids (thickened, raised scars) or other abnormal scars. Although the Treatment received is a superficial peel or enzyme Treatment, I understand that sometimes Treatments penetrate deeper than the superficial epidermis of the skin and that a crusted scab may form. I will call RSMD if this occurs and apply a topical antibiotic ointment twice per day (such as Bacitracin) until the scab resolves.
Waxing. Removal of the top layer of skin may occur resulting in prolonged redness, irritation, pain and rarely scabbing with possible scar formation. Ingrown hair may also be experienced and may result in pigmentary changes including but not limited to dark areas (e.g. hyperpigmentation).
The risks of all products used in Treatments may not be fully known and RSMD is not responsible for any risk or unforeseen complication not yet discovered or not commonly known.
Retinoid and hydroquinone products may cause prolonged irritation, skin flaking, fissuring, hives, increased sun sensitivity. These side effects typically resolve with discontinuation or reduced dosage of product use.
I understand that it is not possible to predict any of the above side-effects or complications and that if any should occur; additional costs for the follow-up treatments necessary to treat these conditions are additional to the cost of my Treatment.
I understand that the practice of medicine is not an exact science, and that no guarantees can be or have been given to me by anyone regarding the condition of my skin, the percentage of improvement expected following Treatments or that a specific result will be achieved. I understand that I may not derive any benefit from Treatments and that there are no guarantees against adverse effects or complications.
Although Treatments may lighten hyperpigmented (dark or discolored) skin, there is no guarantee that hyperpigmentation or uneven pigmentation will improve with Treatments. Due to various factors that influence the skin's condition, no guarantees can be made regarding how long improvement will last in a specific patient.
I have fully disclosed all of my medical history. I understand that it is my responsibility to inform and update RSMD's physician, nurse, skin care specialist or other health care provider of any change in my health status and medical history at each visit, particularly any medication or health conditions that contraindicate treatment. I understand that failure to do so may affect my Treatment outcome and increase the likelihood or severity of complications. All information provided to RSMD 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 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. I have had enough time to consider the information and I have had all questions and concerns answered to my satisfaction. I understand and accept the risks, side-effects and possible complications associated with Skin Care Treatments.
I understand that this document supersedes any and all prior discussions regarding Skin Care Treatments.
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 consent and authorize Dr. Small, a physician assistant, Registered Nurse, or licensed Aesthetician to perform Skin Care Treatments. This consent shall apply to all subsequent Skin Care Treatments.
If I have questions, problems, or any of the above-mentioned side-effects or complications after Treatments I will contact the office of Dr. Rebecca Small (RSMD) directly at (831) 475-1077.
By signing below, I certify that I have fully read and agree to adhere to the pre-Treatment and post-Treatment instructions. 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. I also state that I speak, read and write English.
Skin Care Pre & Post Treatment Instructions
Prior to Treatment
Do not tan, avoid direct sun exposure and use sunscreen daily with SPF 30 or greater for two weeks prior to each treatment and for the duration of your treatment.
Apply the recommended home care products for skin preparation as instructed by your esthetician.
One week prior to treatment, discontinue use of any products containing alpha-hydroxy (such as glycolic or lactic acid) or retinoic acid (such as Retin A, Renova and Differin).
One week prior to treatment, avoid waxing the treated area. You may tweeze or use threading for hair removal.
Treatment areas must be free of any open sores, lesions, and skin infections otherwise treatments may be rescheduled. Moles or skin lesions in the treatment area that have recently itched, bled, or changed in any way, must be checked and clearance received from your personal physician prior to your treatment.
After Treatment
Do not tan, avoid direct sun exposure and use sunscreen daily with SPF 30 or greater for at least four weeks post treatment to minimize complications and side effects.
Skin may appear pink, feel sensitive, tight and dry.
If you have any discomfort, an over the counter pain reliever such as Tylenol may be used. A cool compress may also be applied for 15 minutes every 1-2 hours.
Degree of skin peeling (mild, hardly visible to heavy continuous peeling), will vary and is dependent on the treatment received. Lack of peeling does not indicate that the treatment was ineffective or too weak. Peeling may last for 5-7 days.
These treatments stimulate the skin to renew and generate new skin cells, collagen and increase blood circulation to the skin. Do not pick, abrade or scrub skin that is sensitive or peeling. This may cause surface scarring, irritation and interrupt the skin’s natural rejuvenation process reducing benefits achieved from the treatment.
Apply the recommended home care products for post treatment skin care as instructed by your esthetician. Resume use of regular home skin care products (including alpha-hydroxy and retinoic acids) two weeks after Skin Care Treatment or as instructed by your esthetician/RSMD nurse or physician.
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, exercising, extensive sun or heat exposure, using hot tub and sauna.
Please contact the office of Dr. Rebecca Small (RSMD) at (831) 475-1077 if you have any questions. If problems arise after hours please contact your nearest urgent care facility.