NEHSNORTH EASTERN HEALTH SPECIALISTS

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1 COSMETIC DERMATOLOGY NEHSNORTH EASTERN HEALTH SPECIALISTS nehs.com.au CONSENT FORM ACNE Treatment I, DOB:, of authorize of North Eastern Health Specialist to perform hair removal with the BBL / Nd-Yag laser on the following area(s) of my body The Dermatologists at the North Eastern Health Specialists are trained in the use of BBL and class 4 medical lasers. A certificate in the Safety of Laser Use has been obtained by all members trained in the use of this equipment at NEHS. These members include Dr Shireen K Sidhu (Dermatologist) Dr Hoang Ly (Dermatologist) Mrs Sharon Habib (Registered Nurse) Mrs Helen Marzola (Registered Nurse) BBL (BroadBand Light) for the use in Acne Treatment utilizes light to destroy or minimize P. acnes bacteria, reduce inflammation, and minimize over production of sebaceous oil glands. This therapy may utilize multiple BBL filters (420 nm, 560 nm, 590 nm) to target selectively the P. acnes bacteria and sebaceous oil glands. The goal is to pack the skin with light to impact the entire pilosebaceous unit.

2 Review of facts about light therapy BBL selected filters: 420 nm, 560 nm, 590 nm for the treatment of acne: o The 420 nm filter (blue light) is effective in targeting porphryins. The porphryins are produced by the Propionibacterium acnes bacteria (P. acnes). The blue light will cause photo excitation of these P. acnes porphryins after exposure to the light. This process forms singlet oxygen within the microorganism itself, leading to the selective destruction of the bacteria. o The addition of the 560 nm filter (yellow light) is effective in treating mild to moderate inflammatory acne lesions. o The addition of the 590 nm filter (red light) is effective in treating the deeper lesion that is impacted by the sebaceous oil gland. The red light is heating the gland to aid in minimizing its production of oil. Multiple consecutive sessions will be needed to reduce acne and the severity of lesions. Treatment schedule: number of sessions per week for a minimum of..weeks are necessary as part of the acne therapy program. Pre- and post-care requirements and instructions must be followed. Approximately, a 40-80% reduction in the number of lesions and the prevention of new lesion formation is the expectation from the treatment course. Light from a laser can be harmful to eyes and wearing special safety eyewear is necessary at all times during the procedures. Light from BBL is an intense burst of light and even though the special safety eyewear is in place, you will sense light emanating from the treatment area. The sensation of light may be uncomfortable in certain areas and feel like pin pricks or bursts of heat. Usually the use of topical anesthetic is avoided in light-based acne procedures. The use of topical anesthetics is at the discretion of the practitioner as there are known severe allergic reactions to ingredients in topical anesthetics. Patient s with known allergies to anesthetics will list them here: Common side effects and risks Erythema (redness) may occur in the area of treatment. This may last several hours. Edema (swelling) around the hair follicles is called peri-follicular edema and is a sign that the hair follicle has been affected. Urticaria (itching) or hive-like appearance is also associated with the thermal light affecting the surrounding skin. These symptoms usually subside in a few hours. A cool compress placed on the area provides comfort. The treated area should be cared for delicately for at least 12 hours. Limited activity may be advised, as well as no hot tub, steam, sauna, or shower use. A blister can form up to 48 hours after treatment. An antibiotic cream or ointment can be used. Other short term effects include bruising, superficial crusting, and discomfort. Hyperpigmentation (browning) and hypopigmentation (lightening) have been noted. These conditions usually resolve within 2-6 months. Permanent color change is a rare risk. Vigilant care must be taken to avoid sun exposure (tanning beds included) before and after the treatments to reduce the risk of color change. Sunscreen and / or sun block should be applied when sun exposure is necessary. Avoid fake tans for at least 24 hours

3 Infection is not usual after treatment; however herpes simplex virus infections around the mouth can occur following treatments. This applies to both individuals with a past history of the virus or individuals with no known history. Should any kind of infection occur, your clinician must be notified to prescribe appropriate medical care. Allergic reactions resulting from treatment are uncommon. Some persons may have a hive-like appearance in the treated area as discussed above. Some persons have localized reactions to cosmetics or topical preparations. Systemic reactions are rare. Please tick the following boxes when you are satisfied that the information provided is acknowledged by yourself. If you are uncertain, your Dermatologist is there to discuss this further with you. Please understand that it is crucial you follow the pre and post instructions. In general, BBL is safe with no/minimal complications experienced when conducted by experienced medical and nursing staff. A test area will be performed to ensure that your skin reactions are appropriate. I understand that all standard safety precautions and all BBL specific guidelines will be followed to ensure the utmost in safety during my treatments. This includes the use of protective eyewear at all times while the equipment is in use. I am aware of alternative methods of treatment for hair removal such as topical products, oral treatments and other light-based or laser systems as discussed with my Dermatologist. I have explored such alternatives to my satisfaction, and have made an independent decision to proceed with BBL treatments. My Fitzpatrick skin typing has been analyzed, and I understand that a higher Fitzpatrick typing increases the potential risk of the treatment. Hormonal therapy and other medical conditions may also affect my results. Hair removal with BBL is limited to skin types I-V as complications of the procedure increase with greater skin types. The Nd-Yag laser will be used for skin type VI to prevent the risks described. Results are cumulative; therefore a series of treatments is necessary to achieve maximum benefit. Actual results cannot be guaranteed. I will avoid sun tanning, tanning booths and tanning creams for at least 3 weeks prior to and after all BBL treatments to reduce the risks of uneven pigmentation. I understand that Roaccutane (or other Retinoids taken orally) should not be used for 6 months prior to this procedure. Retin-A (or similar products containing isotretinoin) should not be used 24 hours prior to treatment to minimize irritation. These topical retinoids may be used again one week after the procedure. I understand that treatments cannot be done on skin areas with open sores or lesions. I understand that tattoos and permanent makeup may be altered and that moles may be lightened. We therefore do not treat disease within tattoos and all moles are covered up so as to not be accidentally treated.

4 I understand that recurrent viral infections such as herpes simplex (cold sores) or varicella (shingles) may be activated and that NEHS needs to be informed if there is a history of this. An oral antiviral treatment may be prescribed over the 3 days before, during and after laser/bbl treatment in order to reduce the risk of this infection. I will advice my dermatologist if I am on any anticoagulant (blood thinning) medication (including aspirin) or if there is a history of excessive bleeding or bruising. I will also inform my dermatologist if I have had a history of sun sensitivity or if I am using any sun sensitizing medications. I agree to provide NEHS with an accurate personal medical and drug history prior to treatment. As laser lights may bounce of reflective objects, I understand that all reflective objects such as jewellery and watches must be removed if near the treatment area. I understand that the sensation generated by the light pulse is most commonly described as a rubber band snapping against the skin, and most individuals are able to tolerate this sensation for the short duration of the treatment. I understand that I may have a sunburn type sensation in the treatment area for several hours afterwards and may also experience temporary redness similar to sunburn. Some skin swelling (edema), bruising, blistering, scabbing, infection and other skin changes may also occur especially following facial treatments. I understand that in most cases, all of these effects should resolve over the next several hours to days following treatment. I understand that cold compresses are beneficial, and in extreme cases a mild steroid cream or antibiotic may be necessary and will be prescribed by your Dermatologist. Scarring is extremely rare and usually occurs in those with a predisposition such as a history of keloids or other excessive scarring, but acknowledge that scarring is possible with any patient. I have been advised not to undergo BBL treatments if I have such a history and under these circumstances acknowledge that NEHS cannot be responsible for the outcome of my treatment. I understand that hypo-pigmentation (decreased skin coloration) or hyperpigmentation (increased skin coloration) is uncommon, but if it occurs to me, although rarely permanent, may last several weeks to months. I understand that post treatment use of sunblock is advised to minimize the risk, and that in some cases bleaching creams add additional benefit. Your Dermatologist will guide you on whether this is necessary. I acknowledge receipt of pre and post treatment instructions and that I fully understand that failure to follow these may affect my treatment outcome and increase the likelihood or severity of complications. I also agree to carefully follow these post treatment instructions to reduce the likelihood or severity of any skin changes. Although long term risks of BBL causing pigmentation is not fully known, these complications are unlikely. Studies done have supported their safe use when used by trained individuals. However NEHS cannot be held liable for any BBL risk not yet discovered or is commonly known.

5 I agree that this consent shall apply to all subsequent treatments of a similar nature. I understand that although every reasonable effort will be made to achieve a desirable outcome no guarantees are stated or implied. I certify that I am a competent adult of at least 18 years of age (Minors under 18 years of age require additional consent from a parent or legal guardian.) Photography I do or do not consent to photographs and other audio-visual and graphic materials before, during, and after the course of my therapy to be used for medical, marketing, and education purposes. Although the photographs or accompanying material will not contain my name or any other identifying information. I am aware that I may or may not be identified by the photos. I have read and understand all information presented to me before signing this consent form. I have been given an opportunity to have all of my questions answered to my satisfaction. I understand the procedure and accept the risks. I agree to the terms of this agreement. Patient s Name (Printed): Signature: Date: Name of Doctor/ Reg. Nurse Signature of Doctor/ Reg. Nurse Date: 230 St Bernards Road, Hectorville, SA 5073 Phone: fax:

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