pico combination whitening

File Number:

PICO COMBINATION WHITENING CONSENT FORM

• Most common causes of Skin Darkening (Hyperpigmentation)

• Post inflamatory hyperpigmentation

• Metabolic reaction

• Medical condition

• Hormonal imbalance

• Medication

• Mechanical trauma (fracture)

• Post hair removal (waxing, shaving, threading)

• Trauma (surgical,burn,friction,inflammation)

• Chemical reaction (deodorant, peeling)

• Diet (obesity)

• Hereditary (genetics)

• Dead skin cell accumulation (lack of exfoliation)

• Expect reactions on the treated areas like: darkening, swelling, burns, hypopigmentation, hyperpigmentation, itching and redness. These side effects can be diminished with time but in some cases can stay longer or even permanent.

• Treatment gap is advisable every 3 weeks.

• Laser treatments is not advised for pregnant women.

• Laser treatments is not recommended right before an important event because reactions vary after each session.

• The number of sessions for the different areas varies from person to person therefore results cannot be estimated.

• The results are staged, no guarantees can be or have been made.

• There are no refunds for services rendered.

• The treatment includes picosecond and other related laser technology and non-laser treatment.

I am a competent consenting adult of at least 18 years of age (or my parent or legal guardian is giving consent on my behalf), and further:

• Pre and post treatment instructions have been explained to me.

• Have had the opportunity to ask questions, and all of my questions have been answered to my satisfaction.

• Must notify the clinician if my medical history changes prior to subsequent treatments.

• I consent to clinical photographs being taken of my treated areas for my personal health record only.

• My signature below constitutes my acknowledgment and understanding of all this information.

Patient Name

Patient Signature

Date / Time

Parent or Guardian (if patient is minor)

Witness