Consent for Laser/Light Based Treatment

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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:_____________

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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

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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

COMMENTS CHARGES Signature

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