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Consent for Laser/Light Based Treatment
I authorize Dr. Linda Cook to oversee laser/intense pulsed light cosmetic dermatology treatments on me, including but not limited to deep tissue heating, soft tissue coagulation, hair removal, treatment of pigment- ed lesions, vascular lesions, acne, and/or wrinkles. I understand that the procedure is purely elective, that the results vary with each individual, and that multiple treatments may be necessary.
I understand that:
• Serious complications are rare, but possible.
• Common side-effects include temporary redness and mild “sunburn” like effects that may last a few hours to 3-4 days or longer.
• Pigment changes, including hypopigmentation (lightening of the skin) or hyperpigmentation (darkening of the skin), lasting 1-6 months or longer may occur.
• Freckles may temporarily or permanently disappear in treated areas.
• Other potential risks include crusting, itching, pain bruising, burns, infection, scabbing, scarring, swelling, and failure to achieve the desired result.
• Lasers/intense pulsed light can cause eye injury and protective eyewear must be worn during treatment.
• I understand that sun or tanning lamp exposure and not adhering to the post-care instructions provided to me may increase my chance of complications.
I consent to photographs being taken to evaluate treatment effectiveness, for medical education, training, professional publications or sales purposed. No photographs revealing my identity will be used with out my written consent. If my identity is not revealed, these photographs may be used and displayed publicly without my permission.
Before and after treatment instructions have been discussed with me. The procedure as well as potential benefits and risks have been explained to my satisfaction. I have had all my questions answered. I freely consent to have to proposed treatment.
Patient’s signature:_________________________________________ Date:_____________
Print name:______________________________________________
Witness Signature:__________________________________________ Date:_____________
Print name:______________________________________________
Payment
This procedure is cosmetic in nature; our policy at Riverside Dermatology is that we do not submit to insur- ance. I understand that payment will be my responsibility on the day of the procedure.
Initial:_____________
Last Name:________________________________ First Name:________________________
Address:___________________________________________________________________
City:_____________________________________ State:______ Zip Code:_______________
Date of Birth:_______________________________ Sex: Female Male
Telephone: (Home)___________________ (Work)___________________(Cell)__________________
Family Doctor:______________________________ Phone:____________________________
Pharmacy:_________________________________ Phone:____________________________
Emergency Contact:___________________________ Phone:____________________________
Please answer all of the following questions
1. Do you have ANY current of chronic medical illness? Yes No
If yes, please list _________________________________________________________________
2. Are you currently under a doctor’s care? Yes No
If yes, why? ____________________________________________________________________
3. Do you take/use ANY medication, herbal or natural supplements or topicals on a regular or daily basis?
Yes No If yes, please list ________________________________________________________
4. Do you have ANY allergies to medications, foods, latex or other substances? Yes No
If yes, please list _________________________________________________________________
Medical History
5. (For women) are you or could you be pregnant? Yes No 6. (For women) are menstrual periods regular? Yes No 7. Do you have a history of herpes I or II in the area to be treated? Yes No 8. Do you have a history of keloid scarring? Yes No 9. Have you taken isotretinoin or anticoagulants in the last 6 months? Yes No 10. Do you have any permanent make-up implants or tattoos? Yes No
If yes, please list locations___________________________________________________________
11. Have you had any unprotected sun exposure, used tanning
creams of tanning beds in the last 4-6 weeks? Yes No 12. Which body area/areas or condition would you like treated?
_______________________________________________________________________
_______________________________________________________________________
Signature:____________________________________________ Date:_________________
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Skin Typing Worksheet
Add Above for Total
Score:
Match Your Total Score with the Corresponding
Skin Type
Fitzpatrick Skin Type
______
0-7 8-16 17-25 26-30 Over 30
I II III IV V-VI
Client Name:________________________________ Date:____________ Score:________
What is your eye color?
What is the natural color of your hair?
To what degree do you turn brown?
How does your face respond to the sun?
Do you turn brown several hours after sun exposure?
When did you last expose yourself to the sun, tanning bed, or self-tanning creams?
How often is the area you want to have treated exposed to the sun?
What is the color of your skin (unexposed areas)?
Do you have freckles on sun-exposed areas?
What happens when you stay in the sun too long?
Painful Redness Blistering,
Peeling Light Blue
or Gray
Blue or Green
Hazel or Light Brown
Dark Brown
Brownish Black Red or
Sandy Red Blonde
Dark Blonde Chestnut
Brown
Dark
Brown Black
Reddish Very Pale Pale with
Beige Tint Light Brown Dark Brown
Many Several Few Incidental None
Never Seldom Sometimes Often Always
Never Hardly
Ever Sometimes Often Always
Very
Sensitive Sensitive Normal Very Resistant
Never Had a Problem More Than
3 Months ago
2-3 Months Ago
1-2 Months Ago
Less Than 1 Month Ago
Less Than 2 Weeks Ago Blistering,
Followed by Peeling
Burns, Sometimes Followed by
Peeling
Rarely Burns Never Had Burns
Hardly Any or Not At
All
Light Tan Reasonable Tan
Tans Very Easily
Turns Dark Brown
Quickly
0 1 2 3 4
IPL FLOWSHEET Client Name:________________________________
Medical History Reviewed Photos Consent Signed Skin Typing
Skin Care Instructions Given Hx HSV Y/N Valtrex Y/N Dose:_____________
TREATMENT # DIAGNOSIS HANDPIECE
# OF PASSES SETTINGS mJ MS Jcm2 MS
TREATMENT # DIAGNOSIS HANDPIECE
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TREATMENT # DIAGNOSIS HANDPIECE
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TREATMENT # DIAGNOSIS HANDPIECE
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COMMENTS CHARGES Signature
TREATMENT # DIAGNOSIS HANDPIECE
# OF PASSES SETTINGS mJ MS Jcm2 MS
TREATMENT # DIAGNOSIS HANDPIECE
# OF PASSES SETTINGS mJ MS Jcm2 MS
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TREATMENT # DIAGNOSIS HANDPIECE
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COMMENTS CHARGES Signature
TREATMENT # DIAGNOSIS HANDPIECE
# OF PASSES SETTINGS mJ MS Jcm2 MS
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COMMENTS CHARGES Signature
TREATMENT # DIAGNOSIS HANDPIECE
# OF PASSES SETTINGS mJ MS Jcm2 MS
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# OF PASSES SETTINGS mJ MS Jcm2 MS
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COMMENTS CHARGES Signature
TREATMENT # DIAGNOSIS HANDPIECE
# OF PASSES SETTINGS mJ MS Jcm2 MS
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# OF PASSES SETTINGS mJ MS Jcm2 MS
TREATMENT # DIAGNOSIS HANDPIECE
# OF PASSES SETTINGS mJ MS Jcm2 MS
TREATMENT # DIAGNOSIS HANDPIECE
# OF PASSES SETTINGS mJ MS Jcm2 MS
COMMENTS CHARGES Signature
TREATMENT # DIAGNOSIS HANDPIECE
# OF PASSES SETTINGS mJ MS Jcm2 MS
TREATMENT # DIAGNOSIS HANDPIECE
# OF PASSES SETTINGS mJ MS Jcm2 MS
TREATMENT # DIAGNOSIS HANDPIECE
# OF PASSES SETTINGS mJ MS Jcm2 MS
TREATMENT # DIAGNOSIS HANDPIECE
# OF PASSES SETTINGS mJ MS Jcm2 MS
COMMENTS CHARGES Signature