Vein Go Consent Form

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Patient Information

Patient Name*

Vein Go Consent Form Elimination of Benign Vascular and Pigmented Skin Lesions

I authorize and consent to the treatment for the removal of benign vascular and pigmented skin lesions. The Vein-Go is designed to treat the following conditions and more:

Spider veins, Angiomas, Solar lentigines, Warts, Telangiectasia, Dyschromia, Benign pigmented lesions or Sun damage or Other.

Safe and effective treatment The Vein-Go’s KTP laser safely targets the pigment and warms the blood vessel without damaging either the skin or surrounding tissue. Its 532nm wavelength effectively treats a variety of superficial vascular lesions. Fast treatment, little to no downtime Typically, treatment by the Vein-Go can be applied without anesthesia. While the patient may experience mild discomfort, the procedure is rarely painful.

I have been advised by The Natural Place Med Spa the purported advantages and disadvantages associated with this treatment.

I understand that treatment with this laser system varies from patient to patient and that more than 1-treatment may be required.

Although rare, adverse outcomes such as pain, burning, blistering, stinging, infection, hyperpigmentation and/or hypopigmentation, skin texture changes, and scar formation may 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 elimination of benign vascular and pigmented skin 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 those questions.

I hereby authorize the taking of photographs. These photographs may be used to demonstrate the results this laser produces.

I hereby indemnify and hold harmless Rohrer Aesthetics, LLC, the treating technician, and TNP from any and all liability, damages, cost, and expenses arising from or out of the use of the Vein-GO KTP Laser for treatment of benign vascular and pigmented skin lesions.

With all of the above information understood, I am choosing to be treated with the Vein-Go KTPLaser.

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