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I voluntarily consent and authorize that this treatment be performed by the staff of this clinic, including physicians, practitioners, technicians, and other health care providers as deemed necessary by the staff of this clinic.
I hereby release The Natural Place, its staff, and any other participating health care providers from any and all liability for any adverse effects that may result from this treatment and related procedures.
I understand that the Harmony Pixel is a laser device designed for fractional ablative skin resurfacing and that clinical result may vary in different skin types.
I understand there is a possibility of short-term effects such as reddening, blistering, scabbing, temporary bruising and temporary discoloration of the skin, as well as rare side effects such as scarring and permanent discoloration. These effects have been fully explained to me.
I recognize that this treatment is not an exact science and I acknowledge that no guarantees or assurances have been made to me as to the result or cure.
There are risks related to the performance of these procedures. I understand and acknowledge that the risks that may occur in connection with this particular procedure may include the following:
1) Infection – Albeit rare, skin infection is a possibility any time a skin procedure is performed. I acknowledge and understand that although rare, it is possible for a skin infection to become a blood-borne wide spread infection.
2) Blood clots in veins and lungs –Albeit extremely rare, it may be possible to develop a blood clot associated with this treatment that goes (embolizes) to the heart and/or lungs.
3) Allergic reactions – Although uncommon, I could possibly develop an allergic reaction to medicines applied to the treated area and that I could possibly develop an allergic reaction to any medications that may be prescribed for me.
4) Hemorrhage and bruising – Bruising in the treated area is possible, especially if, within the last ten (10) days, I (we) have taken aspirin or aspirin-containing products, or other medications that “thin” the blood.
5) Painful or unattractive scarring – Scarring is a rare complication of laser assisted treatment, but scarring is possible because the skin surface is disrupted by the laser. To minimize the chances of scarring, it is most important that I follow all postoperative instructions carefully.
6) Discomfort and pain – Some discomfort will be experienced during and after the laser treatment. I give my permission for the administration of topical and/or local injection of anesthesia when and if deemed appropriate.
7) Pigment changes (skin color) – During the healing process, the treated area may become either lighter or darker in color than the surrounding skin. This is usually temporary, but on a rare occasion, it may be permanent.
8) Poor healing – The resultant open wound may require more than the usual one to three weeks to heal.
9) Sun exposure – Once the surface has healed, it may be pink and sensitive to the sun. Treated areas should be blocked completely, that a sun block with and SPF greater than 40 should be used at all times in areas not protected by clothing, whether or not I am in the sun.
10) Blindness and eye damage – The laser, without protective eyewear, may cause visual loss including blindness. It is important to keep these shields on at all times during the procedure and that I should keep my eyes closed in order to protect my eyes from accidental laser exposure.
11) Recurrence– I may not experience permanent results even with multiple treatments. Clinical results may vary depending on individual factors, including medical history, amount of sun damage or textural problems, skin type, patient compliance with pre/post treatment instructions, and individual response to treatment. 303-404-0255 OPT 1 OR www.MEDSPABROOMFIELD.com
I understand and acknowledge that multiple treatments are often required to cause long-term results and that some patients have no results even with multiple treatments. The usual number of treatments required is two to three, but more treatments may be required.
I understand that I am responsible for all costs of the procedure. Alternative treatment methods may include: chemical peels, topical creams, Botox, Juvéderm, laser rejuvenation or no treatment.
I certify that I have been fully informed and I understand that no guarantee can be given as to the final result obtained.
I am fully aware that my condition is of cosmetic concern and that the decision to proceed is based solely on my expressed desire to do so.
I confirm that I am not pregnant at this time, and that I have not taken Accutane within the last 6 months. I do not have a pacemaker or internal defibrillator.
I also have completed a medical history checklist and been informed about what I must do and “not do” before, during and after the series of treatments.
I consent to the taking of photographs and authorize their anonymous use for the purposes of medical audit, education and promotion. I have been given an opportunity to ask questions about my condition, alternate forms of anesthesia and treatment, the procedure to be used, and the risks and hazards involved, and I believe that I have sufficient information to give the informed consent. By signing below, I certify that I have read and fully understand the contents of this document and that I have received and understand all of the disclosures referred to herein.
I certify that I am a competent adult of at least 18 years of age, or that if I am a minor under the age of 18, I understand that the consent of my parent/legal guardian having legal custody will also be required before treatment.
5760 W 120th Ave, Suite 220. Broomfield, CO 80020
11975 Main St. Broomfield, CO 80020