Spectrum Laser System Tattoo Consent

Spectrum Laser System Consent

  • Spectrum Laser System Tattoo, Vein, Laser Hair & Erbium Yag Laser

  • Consent for Treatment for the Removal of Pigmented Lesions Including Tattoo’s

    Using Rohrer Aesthetics, LLC Spectrum Laser System I authorize and consent to the treatment with the Spectrum Laser System manufactured by Rohrer Aesthetics, LLC. I have been advised by, The Natural Place Med spa, 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 trace 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 possibly the elimination of unwanted pigmented lesions and/or the removal of ink used for tattoos. 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 will be shared with Rohrer Aesthetics, LLC and Rohrer Aesthetics may use them in marketing brochures.
  • IPL PRE-TREATMENT INSTRUCTIONS

    1. An accurate diagnosis by a physician is necessary prior to the IPL treatment. 2. Prior to the treatment, clean the treatment area. The treatment area should be free of any makeup, creams, perfumes and lotions. Male patients should shave just prior to treatment (the pigment in your beard could increase discomfort). 3. Discontinue sun tanning, use of tanning beds and any application of sunless tanning products one month before the treatment. 4. Always use an SPF 45/50 sunblock on all exposed treatment areas. Wear sun protective hats and clothing. 5. Discontinue the use of exfoliating creams 1 week prior to the entire treatment 6. If the patient has a history of herpes outbreaks in the areas being treated, a prescribed medication, like Valtrex is recommended for one week prior to the treatment prior to the treatment to help prevent an outbreak. Patients will need to have: ◊ A mild facial cleanser. ◊ A high-quality sunblock SPF 30 (zinc and/or titanium dioxide >10%) ◊ A good moisturizer available for your after-care. ◊ For discomfort, a pain reliever such as ibuprofen or acetaminophen can be used. If an open area occurs or if the treatment area is inadvertently picked an antibiotic ointment, such as Bacitracin can also be applied.

  • Pre-Treatment Advice for Tattoo Removal

    Avoid sun exposure including tanning beds for 2 weeks prior and 2 weeks after the treatment. A cold compress can be applied for 10-15 minutes prior to the treatment. Avoid pain medication such as Motrin, Aleve and aspirin 3 to 7 days prior to the treatment.
  • Consent For Treatment For Skin Resurfacing with the Spectrum Er:Yag Laser System

    I authorize and consent to the treatment for the removal of superficial wrinkles and/or pigmented lesions with the Spectrum Laser System. I have been advised by, The Natural Place Med spa 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 trace scarring could 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 the questions. I hereby authorize the taking of photographs. These photographs may be used to demonstrate the results this laser produces.
  • ERBIUM YAG PRE-TREATMENT INSTRUCTIONS BEFORE THE TREATMENT

    • Discuss and disclose any healing disorders such as caused by diabetes mellitus, connective tissue disease or radiation/ chemotherapy. • Discuss and disclose if there is an active infection or history of herpes simplex of the lips, mouth or face. • Do not proceed with the Erbium Yag treatment if the patient is pregnant or breast feeding. • Discuss and disclose allergies to topical anesthetics, antibiotics, or other medications. • Do not proceed with the treatment if Isotretinoin (Accutane) has been used within the past 12. • Discuss the history of any hypertrophic scarring or keloid formations or other skin diseases. BEFORE FOLLOW-UP TREATMENTS: • Disclose any new medications, you may begin using during your treatment program. • Treatments cannot be performed on areas with a suntan or sunburn. Avoid direct exposure to the sun, tanning beds 4 weeks prior to treatment. A broad-spectrum sunscreen of SPF 45/50 should be applied to any treatment area exposed to the sun.

  • Consent for Treatment for Hair Reduction/Modification with Spectrum 810 diode Laser System.

    I authorize and consent to the treatment of Hair reduction/modification with the Spectrum 810nm Diode laser System manufactured by Rohrer Aesthetics, LLC. I have been advised by, The Natural Place Med spa 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 trace 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 possibly the elimination of unwanted body hair. 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.
  • PRE-TREATMENT HAIR REMOVAL INSTRUCTIONS

    Don't Pluck Prior to a laser hair removal treatment, patients must abstain from tweezing, waxing, or any other unwanted hair treatment that removes hair from its root. There must be hair in the hair follicle for laser hair removal to work. The laser is attracted to the melanin, or pigment, of the hair. The hair must be in its anagen, or active, growth phase. Don't Tan You should also avoid sun exposure in the 4-6 weeks prior to your laser hair removal treatment. Tanned skin has extra melanin, which attracts laser energy. Don't Moisturize Right before your laser hair removal treatment, avoid applying any lotion, sunscreen, perfume, or other similar cosmetics to the surface of your skin. Shave 1-3 days before your session. The idea is to have a nice, close shave, so that there is no hair outside the skin. It is best to have just enough hair to be visible so your laser technician knows what is to be treated. There may be some slight charring of the small amount of stubble that gets hit by the laser. So, if you notice an odor of singed hair, that’s normal.

  • CONSENT FORM For Laser Vein Removal Treatment

    I will be undergoing a vein removal procedure that involves the use of laser application. The physician/technician performing the procedure will be The Natural Place Technicians. This consent is provided as a means of education for vein removal patients. The intent of this consent is to create an understanding between the provider and the patient as to the methods and risk involved in vein removal. It should be understood that laser ablation treatments may need to be repeated several times before complete satisfaction is achieved. No guarantees have been made to me regarding the outcome of the treatment or any improvements in my condition due to the procedure. Risk: 1) Pain, burning, blister formation, and stinging sensation at the site of treatment. 2) Infection associated with the treatment site. 3) Pigmentary (color) changes at the treatment sites including decrease in skin color (hypopigmentation or lightening) and/or increase in skin color (hyperpigmentation or darkening). 4) Scar formation at the treated site. 5) Laser induced “cold sore like” blistering skin eruptions known as “herpetic” skin eruptions at the treatment site or surrounding tissue. 6) Poor cosmetic outcome. 7) Recurrence of vessels at the treated sites. Benefits: 1) Lightening or Removal of veins in the treatment area. 2) Complete removal of veins in the treatment area. I understand this treatment is entirely voluntary on my part. I hereby indemnify and hold harmless Rohrer Aesthetics, LLC and all individuals associated with Rohrer Aesthetics, LLC, the physician and/or the treating technician, and all staff members at the office of The Natural Place Med spa from any and all liability, damages, cost and expenses arising from or out of the use of the Spectrum Laser System. I understand that there will be a charge for this and all consecutive treatments unless arrangements have been made otherwise. I understand that I am making a decision to undergo the treatment, described in the preceding sections and I am subject to the conditions of participation described above. My below signature indicates that I have decided to receive the treatments, having read and understood this information presented above and having been given the opportunity to ask any questions that I might have about the procedure.
  • LASER VEIN PRE-TREATMENT INSTRUCTIONS

    1. Discontinue medications or supplements that may thin your blood one week prior to vein treatments to minimize bruising and improve the success of your treatment. This includes fish oil, flax seed oil, Vitamin E, ginkgo biloba, anti-inflammatory medications (ibuprofen, Motrin, Aleve), and red wine. If you are taking aspirin electively and not upon the advice of your physician, then you may stop it for 48 hours prior to your treatment. Do not stop aspirin if prescribed or recommended by your physician. 2. You may wish to bring a pair of shorts to wear during your treatment if you are having your legs treated. 3. If facial veins are being treated, there may be minor bruising and/or swelling following treatment. This can typically be covered using make-up. Plan accordingly since your face may show slight evidence of the laser treatment for a week or more. 4. If leg veins are being treated, there may be minor bruising, discoloration, and welting over treatment sites. Larger leg veins may appear bruised for a period of time after treatment. Full results can take weeks or months to be realized. Plan and schedule treatments accordingly, allowing for healing time and time for your treatment results to evolve to completion. The best time to treat leg veins are in fall, winter and spring when you are less inclined to wear shorts or be exposed to sun. 5. Plan treatments allowing for a period of no sun exposure, vigorous activity or use of hot tubs, saunas or spas for 48 hours after treatment.