Cosmelan Consent Form

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Informed Consent Form For Facial Depigmentation Treatment Cosmelan

I DECLARE:

Name of physician or therapist

Has explained the advantages and possible initial side effects when undergoing a Cosmelan depigmentation treatment.

1. The purpose of this technique is to remove the most superficial layers of the skin in order to stimulate the cell renovation and as a final result, to obtain an even cutaneous tone and or the total elimination of the melasma.

2. The treatment consists of the elimination of the outmost layers of the skin by the application of chemical agents, by creating a light bum and its consequent reephithelisation.

3. It has been explained to me by the physician /therapist, that in order to obtain best results, I have to strictly follow the home protocol

4. I understand that some side effects can appear such as swelling, pain, high sensitivity, itching, scalping, superficial desquamation, erythema, acne or herpes simplex breakout, hyper or hypo pigmentation of the area treated. The downtime can last for up to five days.

The physician / therapist has warned me to avoid direct sun exposure after each session and I understand the high importance of applying Mesoestetic Dermatological Sun Protection and the Cosmelan Maintenance Cream after the treatment.

The protocol to follow is: 3 daily applications of Cosmelan Maintenance Cream during the first month, 2 daily applications during the second month and one application in the evenings from the third month. Alternatively, I win receive a different protocol from my physician.

I have been informed that the final result depends on strictly following the home maintenance protocol, applying Hydra Vital Factor K a5 many times as necessary during a minimum of six months. This is to restore the hydrolipidic film of the skin.

My clinical findings are important to determine the success of the treatment. It is imperative to check:

Other risks or complications that can appear because of my personal circumstances are:

5. We have decided that Cosmelan is the most convenient treatment for my particular case, although other alternatives are possible. My physician / therapist has discussed these alternatives. The Cosmelan procedure has been explained to me. My questions regarding the treatment, its alternatives, its complications and risks have been answered by the physician or therapist, or by written Information.

I understand all the information given to me. I understand the risks and initial side effect as well as the downtime of the treatment.

My questions have been fully and completely answered. I have read this document and understand its contents.

I give my permission to take photographs of all treated sites for diagnostic purposes and to accurately document the treatment in the usual and customary manner. I agree that these photographs are the property of the clinic.

I will not make any claims or complains either to the business owners, the employees or the manufacturer.

I hereby give my unrestricted informed consent to perform the facial depigmentation Cosmelan procedure.

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Cosmelan Consent Form