Spectrum Laser System Tattoo, Vein, Laser Hair & Erbium Yag Laser Consent Form

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.

I authorize and consent to the treatment for the removal of superficial wrinkles and/or pigmented lesions with the Spectrum Laser System.

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.

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.

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.