I hereby authorize the Doctor or employees, under Doctor supervision to treat my wart(s) using a laser
device. I understand that multiple treatments may be required and it is possible the result will be minimal or
may not help at all.
The procedure may result in the following adverse experiences or risks:
DISCOMFORT/PAIN Discomfort and pain may be experienced during treatment.
REDNESS/SWELLING/BRUISING Short term redness (erythema) or swelling (edema) of the treated
area is common and may occur. There also may be some bruising.
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.
WOUNDS Deep tissue injury and prolonged wound healing may occur. 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.
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 treatment of warts, including the possibility that the procedure may not work
for me.
Alternative treatments such as topical or oral medications or even surgery
Reasonably anticipated health consequences if the procedure is not performed
Possible complications/risks involved with the proposed procedure and subsequent healing period
For women of childbearing age: By signing below 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 Doctor and staff
informed should I become pregnant during the course of 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.
ACKNOWLEDGMENT
BY MY SIGNATURE BELOW, I ACKNOWLEDGE THAT I HAVE READ AND FULLY UNDERSTAND THE
CONTENTS OF THIS INFORMED CONSENT FORM FOR TREATMENT OF WARTS, AND THAT I HAVE HAD ALL
MY QUESTIONS ANSWERED TO MY SATISFACTION BY MY HEALTHCARE TEAM.
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.
