I authorize the office of
Doctor and/or a practitioner, operating under her guidance, to perform laser/light treatments on me, including, but
not limited to, treatment of wrinkles, acne scarring, fine lines, pigmented and creepy skin. I understand this is a
purely elective procedure, that results may vary with each individual, and that multiple treatments may be
necessary.
I understand that there is a possibility of rare side effects, such as scarring, permanent discoloration, as well as short
term effects such as reddening, mild burning, temporary bruising and discoloration of the skin. These effects have
been fully explained to me.
Based on our experience and the experience of many other physicians, we have found those people who tend to
sunburn rather than tan usually obtain the best results. On the other hand, those who tan more easily/darken
quickly tend to have greater variation in their results. Some patients in this category will experience partial
improvement, while others will have minimal results.
I also understand that there are other options for treatment available and each of these other treatments has been
fully explained to me.
I consent to photographs being taken to evaluate treatment effectiveness. No photographs revealing my identity will
be used publicly without my written consent.
I understand that the treatment involves payment at the time of service and the fee structure has been fully
explained to me. I understand that no insurance companies will reimburse for these cosmetic procedures.
For women of childbearing age: By signing below I indicate that I am NOT pregnant. Furthermore, I agree to keep
and staff informed should I become pregnant during the course of treatment
Serious complications are rare but possible, scarring, hyperpigmentation, skin sensitivity.
Common side effects include temporary redness (mild sunburn-like effects) and swelling that may last from a few
hours to a few days. The treated area may remain red and swollen for 2-48 hours. Rarely, veins may initially appear
dark red to purple in color for a few days after treatment, esp. if you have taken a blood thinner.
Pigment changes, including hypo-pigmentation (lightening of the skin) or hyper-pigmentation (darkening of the skin)
lasting from 1-6 months or longer may occur, especially if you are not compliant with sun protection during the
therapy. Freckles may temporarily or permanently disappear in a treated area.
Other potential but rare risks include crusting, itching, pain, bruising, burns, infection, scabbing, and failure to
achieve the desired results.
Laser light could cause serious eye injury; protective eyewear must be worn during treatment.
I understand and agree that I am financially responsible for the payment I made for
that any amount I paid for the sessions or procedures I booked it will only be valid up to 3 months from the
date I made the payment. I understand that I need to utilize the sessions or procedures within 3 months
period. I agree that my payment made is non-refundable or non-transferable post this period.
I declare that I have read and fully understood all points in this consent and that all of my questions were
answered to my satisfaction and I take the full responsibility of my decision in this consent.
Patient Name & Signature :
Doctor/Therapist Name & Signature :
Witness Name & Signature :
Parent or Gaurdian Name (if patient is minor) :
Date :
Consent to be photographed and published
I, , consent to be photographed and published on Social
media, by while before and after the procedure. I further authorize that the
photographs may be published for any purpose and in any form.
