Winchester Laser Cosmetic 6201 Gender Road Canal Winchester, OH 43110 614-837-8031 Informed Consent BBL™ BroadBand Light for Skin Rejuvenation, SkinTyte, and Hair Removal I, ____________________________________________________________, authorize Dr. Dan Konold / Dr. Neil Makadia / or a designated practitioner of Winchester Laser Cosmetic to perform: BBL/IPL Skin Rejuvenation____ SkinTyte____ Hair Removal____ on the following areas of my body:_________________________________________ I understand that the Sciton BBL is intended for benign vascular and pigmented lesions (Skin Rejuvenation), SkinTyte, and/or permanent hair reduction and that clinical results may vary in different skin types. I understand that there is a possibility of rare side effects such as scarring and permanent discoloration as well as short term effects such as reddening, mild burning, blistering, temporary bruising and temporary discoloration of the skin. These effects have all been fully explained to me. Based on the experience of other physicians we have found that those people who tend to sunburn rather than tan usually obtain good results on the first and subsequent visits. On the other hand, those who tan more easily tend to have more variation in their results. Some patients in this category will experience partial results and some will experience no improvement at all. Please read and initial each of the following sections: I understand that purposeful, prolonged exposure to the sun and/or tanning beds in the two weeks prior to and two weeks after a BroadBand Light treatment will result in adverse events, including blistering and hyperpigmentation. I have disclosed my last purposeful UV exposure to my physician and understand that I must be diligent about avoiding the sun/tanning beds and applying a sunblock with an SPF of 30+ for a minimum of two weeks post-treatment. I understand that my treatment(s) involves payment, the fee(s) has been explained to me, and that payment in full is due at time of service. All sales are final and non-refundable. I also understand that there are other options for treatment that are available and each of these other options has been fully explained to me. I understand that pre-treatment photographs will be taken to be included in my medical record and these photos will not be used for other purposes unless I give my consent below. I have had an opportunity to read through my post-care instructions and understand what is required of me during the healing process. I further understand that failure to comply with post-treatment home care may result in adverse events. I understand that medical treatment is not an exact science and the degree of improvement is variable. Occasionally, there is no improvement and alternate treatment options may be recommended. No guarantees, express or implied, have been made regarding the results of my treatment. Initial: _________ Date: ________ Winchester Laser Cosmetic 6201 Gender Road Canal Winchester, OH 43110 614-837-8031 Informed Consent BBL Skin Rejuvenation, Hair Removal, and SkinTyte Page 2 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 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: ____________Witness:________________ Initial: _________ Date: ________
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