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Consent For Laser Treatment
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Name
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First
Last
Full IC Number / FIN
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Todays Date
Authorization
I hereby authorize the MOH registered doctor to remove or lighten the appearance of vascular lesions/ pigmentation or to remove benign lesions. I understand it may take multiple treatments to obtain optimal results. Although these devices are effective in most cases, no guarantees can be made. I understand I may not experience complete clearance. Some conditions may not respond at all and, in rare cases, may become worse.
The procedure may result in the following adverse experiences or risks:
DISCOMFORT / PAIN– Some discomfort may be experienced during treatment. Pain may include the feeling of burning, stinging and radiating pain.
REDNESS/SWELLING– Short term redness (erythema) or swelling (edema) of the treated area is common and may occur An urticarial (hive-like) reaction may occur with smaller vessels
PURPURA / BRUISING: Purpura (bruising) is a transient phenomenon that usually resolves with time.
HEMOSIDERIN STAINING: (iron leaking into tissue from blood breakdown) may occur and usually resolves over time, but it may be permanent.
SKIN COLOR CHANGES – During the healing process, there is a possibility that the treated area may become either lighter (hypopigmentation) or darker (hyperpigmentation) in color compared to the surrounding skin. This is usually temporary, but, on a rare occasion, it may be permanent.
SKIN CRUSTING – Epidermal crusting may develop. It is important not to disturb the crusts. May require medication if sensitivity or redness occurs. Crusts will typically slough 7 to 14 days after treatment.
WOUNDS – Treatment can result in burning, blistering, or bleeding of the treated areas. If any of these occur, please call our office.
INFECTION – Infection is a possibility whenever the skin surface is disrupted, though proper wound care should prevent this. If signs of infection develop, such as pain, heat or surrounding redness, please call our office.
SCARRING – Scarring is a rare occurrence, but it is a possibility if the skin surface is disrupted. To minimize the chances of scarring, it is IMPORTANT that you follow all post-treatment instructions provided by your healthcare staff.
TEXTURAL CHANGES/ Skin INDENTATIONS – May occur as a result of heat diffusion and thermal injury to tissue surrounding vessels.
UNDESIRABLE HAIR REDUCTION: Hair reduction may occur at treatment sites. This is usually temporary but may be permanent.
SUN EXPOSURE / TANNING BEDS / ARTIFICIAL TANNING – May increase risk of side effects and adverse events.
EYE EXPOSURE – Protective eyewear (shields) will be provided to you during the treatment. Failure to wear eye shields during the entire treatment may cause severe and permanent eye damage.
I acknowledge the following points have been discussed with me:
Potential benefits of the proposed procedure, including the possibility that the procedure may not work for me
Possible complications/risks involved with the proposed procedure and subsequent healing period
Other options are explained to me
or women of childbearing age: I confirm that I am not pregnant and do not intend to become pregnant anytime during the course of treatment. Furthermore, I agree to keep Dr and staff informed should I become pregnant during the course of treatment. Photographic documentation will be taken for record and for teaching purposes.
ACKNOWLEDGMENT
BY MY SUBMISSION BELOW, I ACKNOWLEDGE THAT I HAVE READ AND FULLY UNDERSTAND THE CONTENTS OF THIS INFORMED CONSENT FOR THE USE OF LASERS, AND THAT I HAVE HAD ALL MY QUESTIONS ANSWERED TO MY SATISFACTION BY MY HEALTHCARE TEAM.
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