Laser Hair Removal Consent Form – Fill Out and Use This PDF

INFORMED CONSENT FOR LASER HAIR REMOVAL

INSTRUCTIONS

This informed consent document has been prepared to help inform you about laser procedures, its risks, as well as alternative treatment(s). It is important that you read this information carefully and completely. Please initial each page indicating that you have read the page and sign the consent for surgery as proposed by us and agreed upon by you.

GENERAL INFORMATION

Trying to get rid of unwanted hair on the face or body is a common problem. Laser hair reduction offers results that cannot be achieved with conventional shaving or waxing. The laser works by targeting the hair in the follicle, below the skin’s surface. The lasers we use in our medial spar are FDA approved and safe and effective. The laser energy is transformed into heat which destroys the hair follicle leaving the surrounding skin unaffected. Facial areas, bikini area, upper and lower legs, arms, chest, and back may be treated leaving the skin smooth, stubble free, and without the irritation of ingrown hairs. In an hour or less, most body areas can be hair free. While some areas of the body are more sensitive than others, most patients report little or no discomfort. Again, this is a no down time procedure.

Hair grows in cycles. A minimum of four to six treatments will be necessary as the process is mot effective on hair during the early growth cycle. After each session you will see substantial visible hair reduction. Each laser hair removal treatment will result in hair growth reduction. Additionally, hair will grow progressively slower, lighter, and finer with each treatment. It takes more than one treatment to affect all the follicles growing in an area.

The number of sessions will vary for each individual. During the initial visit the laser light disables those follicles in the “active” phase of the growth cycle. Follicles in the “dormant” phase will not be affected. Since follicles cycle through “active” and “dormant” phases, additional sessions may be desired once the “dormant” follicles become “active.” For this reason we recommend a series of treatments. Most people achieve satisfactory clearance after four to six treatments, but individual results may vary depending on medical and genetic factors. Lighter colored hair may require more treatments than darker colored hair.

Since no procedure can guarantee permanent hair removal, most patients can expect a 60% to 70% reduction in hair growth.

Remember, the laser is FDA approved for permanent hair reduction, not removal. The extent of long- term hair reduction will vary among clients because of the nature of hair and the many factors that influence the growth of hair. After the initial full course of treatments there should be little hair re- growth. This re-growth will require future laser hair removal treatments to sustain hair reduction. Note: Multiple treatments will be required to achieve optimum results. All payments are strictly nonrefundable.

ALTERNATIVE TREATMENTS

Alternative forms of treatment include not undergoing the proposed laser procedures like razors.

Risk of Laser Procedure, continued

INSTRUCTIONS

Pre-Treatment

Avoid tanning for 2-3 months.

Avoid waxing, tweezing, or depilatory use for 6 weeks.

Avoid irritants such as products containing glycolic acid or Retin-A in the area for 5 to 7 days. No Accutane for 6 months prior to treatment.

Shave the desired treatment area the night before laser treatment.

Wear loose, comfortable clothing on the day of treatment so as not to irritate the treated area.

Post-Treatment

The areas treated with the laser may be red following treatment. This will generally fade within 2-3 days. The treated area can be washed normally with mild soap and water. Wash the area gently with your fingertips. Use of a washcloth or other abrasive instrument is not recommended.

Cover the treated area with a sunscreen of SPF 15 or higher and avoid sun exposure to the treated area for 4 to 6 weeks. No direct sun exposure for at least 2 weeks.

Avoid irritants such as products containing glycolic acid or Retin-A in the area for 5 to 7 days. No deodorant to the treated area for 48 hours.

Minor crusting or scabbing of the treated area can occur following treatment. Do not rub or pick the scab. Wash gently with fingertips and mild soap. Apply an antibacterial ointment to the treated area. Apply 1% hydrocortisone or Aloe Vera to the treated area as redness occurs.

Hair remaining in the follicle with extrude typically within 1 to 2 weeks after treatment. This will look like growth, but is simply the body’s way of eliminating the hair from the injured follicle. On the third day post treatment you may shaver or gently wash the area to help loosen hair that is still embedded in the follicles.

No exercise until the perifollicular edema (red bumps) resolves.

No Jacuzzi, sauna, or stem baths until the skin is back to normal.

RISKS

Every procedure involves certain amount of risk and it is important that you understand these risks and the possible complications associated with them. The following are some of the risks.

Scarring: Although good wound healing after a procedure is expected, abnormal scars may occur within the skin and deeper tissue. In rare cases, keloid scars may result. In some cases scars may require surgical revision or treatment.

Burns: Laser energy can produce burns. Additional treatment may be necessary to treat laser burns.

Risk of Laser Procedure, continued

Accutane (Isotretinoin): This drug may impair the ability of skin to heal following treatments or surgery for a variable amount of time even after the patient has ceased taking it. Individuals who have taken this drug are advised to allow their skin adequate time to recovery from Accutane before undergoing laser treatment procedures.

Fire: Inflammable agents, surgical drapes and tubing, hair, and clothing may be ignited by laser energy.

Laser Smoke (plume): Laser smoke is noxious to those who come in contact with it. This smoke may represent a possible biohazard.

Infection: Although infection following laser skin procedures is unusual, bacterial, fungal, and viral infections can occur. Herpes simplex virus or zoster infections can occur following a laser treatment. Should an infection occur, additional treatment including antibiotics, hospitalization, or additional surgery may be necessary. If you have cold sores, herpes, or zoster, do please tell us prior to the laser treatment. Medications must be prescribed and taken both prior to and following the laser treatment procedure in order to suppress an infection from this virus.

Damaged Skin: Skin may heal abnormally or slowly following treatment by lasers or other surgical techniques. The occurrence of this is not predictable. Additional treatment may be necessary.

Skin Contour Irregularities: Contour irregularities and depressions may occur after surgery. Visible and palpable wrinkling of skin can occur. This may improve with time or can be surgically corrected.

Pain: You may experience some mild pain after the laser treatment. Chronic pain is very rare.

Unsatisfactory Result: Although good results are expected, there is no guarantee or warranty expressed or implied on the results that may be obtained. This would include risks such as unacceptable visible deformities, skin slough, loss of function, poor healing, wound disruption, permanent color changes in the skin, and loss of sensation. Additional procedures may be needed to attempt to improve your results.

Lack of Permanent Results: Laser hair removal is not permanent.

Visible Skin Patterns: Laser procedures may produce visible patterns within the skin. The occurrence of this is not predictable.

Distortion of Anatomic Features: Laser procedures can produce distortion of the appearance of the eyelids, mouth, and other visible anatomic landmarks. The occurrence of this is not predictable. Should this occur, additional treatment including surgery may be necessary.

Skin Discoloration/Swelling: Some swelling normally occurs following laser procedures. The skin in or near the surgical site can appear either lighter or darker than surrounding skin. Although uncommon, swelling and skin discoloration may persist for long periods and in rare situations may be permanent.

Risk of Laser Procedure, continued

ADDITIONAL TREATMENT NECESSARY

There are many variable conditions which influence the long term result of laser procedures. Even though risks and complications occur infrequently, the risks cited are the ones that are particularly associated with these procedures. Other complications and risks can occur, but are even more uncommon. Should complications occur, additional surgery or other treatments may be necessary. The practice of medicine and surgery is not an exact science. Although good results are expected, there is no guarantee or warranty expressed or implied on the results that may be obtained.

PATIENT COMPLIANCE

Follow all physician instructions carefully. This is essential for the success of your outcome. Postoperative instructions concerning appropriate restriction of activity, use of dressings, and use of sun protection must be followed in order to avoid potential complications, increased pain, and unsatisfactory result. It is important that you participate in followup care, return for aftercare, and promote your recovery.

FINANCIAL RESPONSIBILITIES

This surgery/procedure, you acknowledge that you have been informed about its risk and consequences and accept responsibility for the clinical decisions that were made along with the financial costs of all future treatments.

DISCLAIMER

Informed consent documents are used to communicate information about the proposed surgical treatment of a disease or condition along with disclosure of risks and alternatives forms of treatment(s) including no surgery. The informed consent process attempts to define principles of risk disclosure that should generally meet the needs of most patients in most circumstances.

However, informed consent documents should not be considered all inclusive in defining other methods of care and risks encountered. Your plastic surgeon may provide you with additional or different information which is based on all the facts in your particular case and the current state of medical knowledge.

Informed consent documents are not intended to define or serve as the standard of medical care. Standards of medical care are determined on the basis of all of the facts involved in an individual case and are subject to change as scientific knowledge and technology advance and as practice patterns evolve.

It is important that you read the above information carefully and have all of your questions answered before signing the consent.

PATIENT: _______________________________________ DATE: ________________________