C02 Fractional Laser by Phoenix

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Patient Information

Patient Name*

C02 Fractional Laser by Phoenix Consent Form

I authorize and consent to the treatment for the Phoenix-15 CO2 Laser. C02 uses the most advanced skin revitalization laser treatment technology and has been shown to produce astounding anti-aging results for skin care patients. In fact, studies prove that the fractional CO2 treatment not only reduces the effects of aging on the skin, but also reverses existing signs of aging, including:

– Acne and other trauma-related scars, – Age Spots, – Wrinkles, – Crow’s feet, – “Smoker’s Lines”

After just one treatment, skin appears significantly healthier, rejuvenated, and smoother than prior to the treatment.

The fractional CO2 laser treatment works by using a pattern of carbon dioxide laser beams to treat the skin below the surface. Your technician sends carbon dioxide beams into the skin. The beams create strategically placed microscopic holes in the skin that allow the body to start producing more collagen. Collagen is the body’s natural hormone that keeps the skin healthy and youthful. The secret to the effectiveness of the fractional CO2 laser technology rests in the fragmented nature of its treatment patterns. This treatment does not allow its laser energy to affect all parts of the skin at once. Instead, it affects a portion of the skin and not the entire skin’s surface. This allows the recovery time to speed up, thereby enhancing results. Patients are usually fully healed within four to five days on average.

Additionally, while the treatment is not in any way painful, there are some sensations that patients can look out for. These sensations include a slight sunburned feeling accompanied by some peeling. Thankfully, these symptoms usually pass within the average healing and recovery time of about four to five days. The results, however, are practically immediate, and patients will notice that their scars, wrinkles, age spots, and other skin conditions are far less noticeable as the skin continues to heal. As time goes on, the skin continues to clear as the newly produced collagen helps the skin become tight, moisturized, and vibrant.

I have been advised by, _____________________________________________ of _________________________________________ of the purported advantages and disadvantages associated with this treatment.

I understand that treatment with this laser system varies from patient to patient and that that more that 1-treatment may be required. Although rare, adverse outcomes such as hyperpigmentation and/or hypopigmentation (darkening or lightening of the skin), skin texture changes, and scarring can occur.

No guarantees have been made to me regarding the outcome of the treatment or any improvements in my condition due to the procedure.

I understand that the possible benefits are the reduction and the elimination of wrinkles and pigmented lesions.

Due to the brilliance of the laser light energy used, I agree to wear eye protection to shield my eyes.

I have been given the opportunity to ask questions and have received satisfactory answers to those questions.

I hereby authorize the taking of photographs. These photographs may be used to demonstrate the results this laser produces.

I hereby indemnify and hold harmless Rohrer Aesthetics, LLC, the treating technician and TNP from any and all liability, damages, cost and expenses arising from or out of the use Phoenix-15 CO2 Laser for treatment of wrinkles and/or the removal of pigmented lesions.

With all of the above information understood, I am choosing to be treated with the Phoenix-15 CO2 Laser.

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