Pico Lazer Consent Form

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Patient Information

Patient Name*

Pico Lazer Consent Form

Consent for treatment of Contraindications

Lip augmentation with Pico Laser is a new option for patients who are scared of needles, the results are immediately visible and last for 3 weeks and the treatment takes 15 minutes and it has no side effects. The lip will be swollen immediately because of inflammation which lasts for 24 hours. Patients will have superficial peeling after 3 days and finally after 30 days collagen reaction will give the lips a fuller look and make them rejuvenate, fill and plump. So the laser lip rejuvenation enhances lips to give them a fuller, more natural appearance through the use of laser energy and the process of collagen regeneration. It is a non-surgical and non-invasive treatment that has no cutting or puncturing of the skin with minimal discomfort, minimal risk of change in skin or lumpiness in the area.

Using the Pico Lazer laser is contraindicated for those patients who:

•Are hypersensitive to light in the near infrared wavelength region

•Take medication which is known to increase sensitivity to sunlight

•Have seizure disorders triggered by light

•Take or have taken oral Isotretinoin, such as Accutane®, within the last six months

•Have active localized or systemic infection, or an open wound in area being treated

•Have a significant systemic illness or an illness localized in area being treated such as lupus.

•Have common acquired nevi that are predisposed to the development of malignant melanoma

•Have active herpes simplex in the area being treated

•Are receiving or have received gold therapy

Precautions: Have any suspicious skin lesions or known history of keloid scarring.

The Pico Lazer laser produces an intense burst of light that is absorbed by the pigmented lesion or tattoo ink. All personnel in the treatment room, including me, will wear protective eyewear to prevent eye damage from this intense light.

The sensation of the laser light on skin is uncomfortable and may feel like a slight pinprick or the sensation of heat. These sensations may last for a few hours.

Tattoos may blister and have pinpoint bleeding immediately and for a few days after treatment.

I have been informed that hyperpigmentation (darkening of the skin), and hypopigmentation (Lightening of the skin) are possible complications of the procedure.

I understand that sun exposure, before or after treatment, as well as not adhering to the post treatment instructions provided to me may increase my chance of complications.

Some adverse reactions may include blistering, scabbing, crusting, pustules, burns, erythema, edema and scarring.

Following a facial treatment, the treated areas may red, bronzed, slightly swollen and rarely may develop an acne-like breakout. Your skin may become very dry and flaky. Pigment may darken for a few days. These conditions may last a few hours up to a few days.

I have informed the laser operator if I have any permanent cosmetic ink. (We do not treat cosmetic tattoos, as they may turn gray or green.)

The area should be treated delicately following treatment. Multiple treatments may be necessary, and there is no guarantee that all ink or all pigment will be removed.

I have read and understood all information presented to me, and I have been given an opportunity to ask questions before signing this consent.

I hereby indemnify and hold harmless Rohrer Aesthetics, LLC and their employees, the treating technician and the staff at the office of TNP from any and all liability, damages, cost and expenses arising from or out of the use of the Pico Lazer.

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