Consent for Laser/Light Based Treatment

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1 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 pigmented 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: Print name: Witness Signature: Print name: Date: Date: Payment This procedure is cosmetic in nature; our policy at Riverside Dermatology is that we do not submit to insurance. I understand that payment will be my responsibility on the day of the procedure. Initial: Continued on next page

2 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: Continued on next page

3 Skin Typing Worksheet Client Name: Date: Score: What is your eye color? What is the natural color of your hair? What is the color of your skin (unexposed areas)? Do you have freckles on sun-exposed areas? Light Blue or Gray Red or Sandy Red Reddish Blue or Green Blonde Very Pale Hazel or Light Blonde Chestnut Pale with Beige Tint Light ish Black Black Many Several Few Incidental None What happens when you stay in the sun too long? Painful Redness Blistering, Blistering, Followed by Burns, Sometimes Followed by Rarely Burns Never Had Burns To what degree do you turn brown? Do you turn brown several hours after sun exposure? Hardly Any or Not At All Light Tan Reasonable Tan Tans Very Easily Turns Quickly Never Seldom Sometimes Often Always How does your face respond to the sun? Very Sensitive Sensitive Normal Very Resistant Never Had a Problem When did you last expose yourself to the sun, tanning bed, or self-tanning creams? More Than 3 Months ago 2-3 Months Ago 1-2 Months Ago Less Than 1 Month Ago Less Than 2 Weeks Ago How often is the area you want to have treated exposed to the sun? Never Hardly Ever Sometimes Often Always Add Above for Total Score: Match Your Total Score with the Corresponding Skin Type Over 30 Fitzpatrick Skin Type I II III IV V-VI

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:

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