"A Whole New You"
"Mini" Non-Invasive
Extreme Makeover"
Consent and Disclosure
Form
Download this Consent and Disclosure in a .doc format
Preliminary Remarks
The “Mini” Non-Invasive
Extreme Makeover Program designed to introduce you to some
of the new technology available to improve the health and
appearance of the skin. It addresses most of the concerns
that clients express such as unwanted pigmentation (browns
and reds), poor texture, fine wrinkles and sagging. It is a
series of 6 treatments performed over a 6-10 week period by
Dr. Christian and our Aesthetician. However, It should be
used only as an adjunct to well planned skin care program
consisting of twice daily cleansing, some form of
exfoliation, moisturizing and sun protection. We will
review your current program of skin care and work with you
to make sure you are using appropriate products for your
skin type during the initial consultation. It is important
that your skin be healthy before we apply some of the
technology to be sure we get rapid healing and the best
results. We may determine that your skin needs a month or
two of skin care prior to any of the laser or light
treatments. We promote primarily the SkinCeutical line of
products and these can be purchased from us at a 10%
Discount or in a special package we have designed. In
addition there may be other products which may reduce the
appearance of unwanted pigment and wrinkles or which may
enhance the effects of the procedures we will perform. It
makes no sense to apply some of the high technology
procedures we will be using and not be committed to a daily
program of skin care for maintenance and prevention of
further damage. Much can be done over time with a daily skin
care program especially in terms of moisturizing/hydrating
and sun protection. The procedures in the “Mini”
Non-Invasive Extreme Makeover program are designed to hasten
the improvement of your skin health and appearance but this
occurs best when the skin is well hydrated and nourished.
We cannot proceed with the “Mini” Makeover without your
commitment to a daily skin care program. It should be
understood that a single series of treatments is unlikely to
achieve the final desired results and that a second or third
“Mini” series will most likely be required. This program
allows you to see the results of a single series of
treatments and then you can decide regarding further
treatments.
I understand the importance
of a daily skin care regimen and I agree to utilize products
appropriate to my skin type as recommended by Dr. Christian.
If I cannot afford a basic program of skin care products I
understand I cannot participate in the “Mini” Non-Invasive
Extreme Makeover. Skin Care Products are not included in
the cost of the program and in some cases you may need
additional products to enhance the results of your program
or post treatment care. The cost of these is not included
in the program. The initial cost of a supply of basic skin
care products may be about $200-$400. ____Initials
I have seen Dr. Christian’s
PowerPoint Presentation regarding the procedures to be
applied including the Diamond Microdermabrasion, “Pixel”
Laser Skin Resurfacing, Infrared Skin Tightening and Intense
Pulsed Light.
____Initials
The Program, Summary (May
vary with your needs)
Initial Consultation,
Digital and UV Light Pictures and review of Your Skin Care
Product Program.
1 Diamond Microdermabrasion
with Javani Procedure
1 Intense Pulsed Light
Treatment of Face for Pigmentation
1 Diamond Microdermabrasion
with Javani Procedure
1 “Pixel” Laser Skin
Resurfacing of the Face to include
1 Infrared Skin Tightening
Procedure.
1 Diamond Microdermabrasion
with Javani Procedure
____Initials
Expected Results
Direct Effect
of a series of Diamond Microderms with Javani
Improvement
in the smoothness and texture of the skin because of
efficient removal of the outer dead layer of skin followed
by Javani Hydration.
Direct
Effect of a series of “Pixel” Laser Skin Resurfacing
Marked
improvement in the appearance of fine wrinkles around the
eye and mouth.
Marked
improvement in the appearance of acne scaring and traumatic
scaring.
Marked
improvement in the smoothness and texture of the skin.
Increase over
time of Collagen, Elastin and Thickness of Epidermis
enhancing the results of the immediate shedding and regrowth
of the epidermal layer.
Direct Effect
of a series of Intense Pulsed Light
Improvement in
the appearance of brown spots and redness/flushing of face.
Direct Effect
of a series of Harmony Infrared Skin Tightening
Gradual
improvement will be seen in sagging of the jowls and the
skin of the neck after a series of treatments.
Direct Effect
of a Long Term Skin Care Program
Over the long
term there will continue to be some improvement in some of
the following areas with a program of daily skin care & not
due to the “Pixel” Laser, Intense Pulsed Light or Infrared
Skin Tightening.
Reduction in the
appearance of pigment, brown or dark lesions
Reduction
in redness, flushing, small vessels, Rosacea
The skin will be
more even toned and smoother
Continued
Reduction in the appearance of fine wrinkles
Reduction in the
occurrence of breakouts and blemishes
Increased
Collagen, Elastin, thickness of Epidermis
Unfortunately,
there will be continued sun exposure and progression of the
aging process therefore followup procedures and Skin Care
Products will be required to sustain improvements of some
lesions for the long term.
____Initials
The Program, Details
Pre Program Diamond
Microdermabrasion and Javani
Most Clients will have a
Diamond Microdermabrasion and Javani Procedure prior to your
formal consultation to give you some idea of how profoundly
even a single treatment using Medical Grade Techniques can
improve the texture and appearance of your skin. At this
session Dr. Christian will explain some of the basics of
skin care and some pictures will be taken.
____Initials
Initial Consultation and
Treatment
During this consultation,
Dr. Christian will review your present Skin Care program and
determine your Fitzpatrick Skin Type. More pictures will be
taken and the face and body will be examined for “targets”
for treatment. A list of these “targets” and our objectives
will be made and a preliminary plan for treatment will be
formulated. This plan may change depending on how your skin
responds as the program progresses. If we feel the skin
needs some rest for rejuvenation, we may delay some
treatments until the skin is ready for more care. During
this period, consistent use of skin care products
is critical to allow the
skin to renew and repair. If suspicious cancerous lesions
are discovered during this consultation, referral to
Dermatologist will be made for resolution prior to the
treatments.
____Initials
Indications
Indications For Use of “Pixel” Laser
resurfacing
A series of “Pixel” Laser
procedures assists in the treatment of the following skin
conditions:
-
Skin
resurfacing for rough skin
-
Treatment of wrinkles around eyes, mouth
-
Some
Pigmentation will respond
-
Skin
tags
-
Scars
including acne scars
__Initials
Indications For Use of Intense Pulsed
Light
A series of IPL procedures assists in the treatment of
the following skin conditions:
-
Vascular changes,
including spider veins, broken capillaries and the
redness and flushing associated with Rosacea.
-
Pigmentation changes,
including brown/black spots or freckles associated with
aging and sun damage.
-
Large pores will be
reduced in size and appearance.
-
Improvement in acne and
other inflammatory lesions are reduced
-
Some congenital vascular
lesions such as hemagiomas
-
Reduction in the redness
of old scars
-
Some improvement in fine
wrinkles and skin laxity over the long term with
continued maintenance treatments several times per year.
-
Some resolution of
Actinic Keratoses with use of Levulan.
____Initials
Indications For Use of Infrared Skin
Tightening
A series of Infrared Skin
Tightening procedures assists in the treatment of the
following skin conditions:
__Initials
Contraindications
Contraindications For Use of “Pixel” Laser
Skin Resurfacing or Intense Pulsed Light or Infrared Skin
Tightening
These procedures should
not be performed if any of the following apply:
-
I am an uncontrolled
diabetic and/or subject to poor healing
-
History of Keloid Scar
formation
-
Pregnancy
-
Active tanning in the
sun or in Tanning Booths/Beds for 4 weeks prior to the
treatment.
-
Fitzpatrick Skin Types V
and VI. Dark Brown or Black skin
-
Use of Accutane in the
6-9 months prior to the treatment
-
Use of Retin A if
irritation and redness is present
-
Use of anticoagulants
such as Coumadin or Heparin or large doses of daily
aspirin.
-
Botox or Restylane in
the prior 2 weeks in the area to be treated.
-
Scleroderma
-
Prior Radiation in the
treatment area
-
Open Sores, infection,
wounds or uncontrolled Acne.
-
Active herpes simplex
(cold sores) or shingles.
-
Use of Sun Sensitizing
Medications
-
Suspicion of cancerous
lesions. None of these apply
___Initials
Mechanisms of Action
Mechanism of action of
the “Pixel” Laser
The “Pixel” Laser Device
produces a beam of highly concentrated light at a wave
length of 2960nm delivered in a pulse of varied duration and
energies. This wavelength is very highly absorbed by water,
which is the primary target. Clients with very hydrated
skin (dermis and epidermis) will have a more pronounced
result. Once the water absorbs the light, it is converted
to heat which in turn damages/destroys/vaporizes the
undesirable target tissue. A portion of the epidermis will
be damaged which then sheds over 5-7 days leaving a smoother
texture and fine wrinkles and scars are diminished. The
“Pixel” laser will penetrate also into the dermis and heat
up water which then denatures collagen leading to the
formation of new or remodeled collagen which then over the
long term smoothes and tightens the skin. In this procedure
the Laser Pulse is divided into either 49 or 81 smaller
pulses which only damages a fraction of the skin, leaving
much normal skin to aid in the healing process. The body’s
natural healing process then occurs and the damaged tissue
will flake off over a period of 5-7 days. The settings on
the device consist of the duration of the pulse and the
energy and are determined by your skin type and the type of
target lesions. Initially the settings are on the low side
to test how your skin will react to the pulse and at
subsequent sessions the settings are increased or
adjusted to get maximum
results with minimal side effects. A “Conservative”
Treatment would entail only a single pass. A “Moderate”
Treatment would entail 2 passes in different directions and
an “Aggressive” Treatment would entail 2-3 passes with
“stacking” of pulses in problem areas.
____Initials
Mechanism of action of
Intense Pulsed Light
The IPL Device produces a
broad beam of highly concentrated light delivered in a
pulse. This light is filtered to a wavelength that is
selectively absorbed by target tissues, (the lesions we want
to treat) with hopefully minimal effect of the surrounding
skin. Once the target absorbs the light, it is converted to
heat which in turn destroys the undesirable target tissue.
The body’s natural healing process then absorbs the damaged
tissue or the damaged tissue will flake off over a period of
days to weeks. The settings on the device consist of the
duration of the pulse and the energy and are determined by
your skin type and the type of target lesions. Initially
the settings are on the low side to test how your skin will
react to the pulse and at subsequent sessions the settings
are increased or adjusted to get maximum results with
minimal side effects.
____Initials
Mechanism of action of
Infrared Skin Tightening
The Infrared device
produces a broad beam of highly concentrated light in the
Infrared range delivered in a pulse. This light is filtered
to a wavelength that is selectively absorbed by water in the
dermis producing heating of the water. Once the water is
heated, there is denaturing of the collagen with subsequent
remodeling which results in some tightening of the overlying
skin. These changes occur over time and the final result
might not be apparent for 4-6 months after a treatment. This
is the time that is needed for collagen remodeling to occur.
There will be no shedding of skin with this procedure and
it will be done just prior to the “Pixel” Laser Procedure.
____Initials
Alternatives to “Pixel”
Laser Skin Resurfacing, Intense Pulsed Light and Infrared
Skin Tightening
I understand that these
procedures are used as an adjunct to a comprehensive program
of skin care and a prolonged course of these products may
achieve some of the desired skin changes I am seeking. I
have explored these alternatives to my satisfaction and have
made an independent decision to proceed with this series of
treatments in the hope that the desired skin changes may be
more rapid, effective and more lasting.
____Initials
Limitations
I understand that some
improvement is achieved in nearly everyone, but that my
results and/or complete resolution of the undesirable target
lesions are not expected to occur with a single series of
treatments. Results are limited by many factors including
the equipment capability as well as my personal skin
characteristics. My Fitzpatrick Skin Typing has been
analyzed and I understand that a higher Fitzpatrick Typing
increases the potential risk of the treatment. Currently,
“Pixel” Laser Skin Resurfacing and Intense Pulsed Light are
limited to Fitzpatrick Skin Types I – IV. Hormonal therapy
and other medical conditions may affect my results. Results
are cumulative and a series of treatments as well as a well
planned program of skin care products are necessary to
achieve maximum benefit. Actual results cannot be
guaranteed. My
Fitzpatrick Skin Type is _____.
____Initials
Side Effects and
Complications
Procedural Discomfort
“Pixel” Laser Skin
Resurfacing
Pain and discomfort
during the actual procedure of “Pixel” Resurfacing is
minimal and many comment only that they feel a slight snap
or electrical tingle with each Laser Pulse. At the end of
the procedure the skin will start to feel slightly like a
sun burn. At this time cold wash cloths and air will be
blown on the face which relieves this to some extent. We
will place some Javani Gel and other Hydrators such as B-5
Hydration Gel Prior to your departure. We may also use a
light coat of a 1% Hydrocortisone Cream.
____Initials
Intense Pulsed Light
Pain and discomfort
during the procedure are the most common described side
effects. The pain is similar to a rubber band snapping
against the skin and most individuals are able to tolerate
this sensation for the short duration of the treatment. Dr.
Christian may apply a topical anesthetic prior to the
procedure in some individuals. I cannot have a topical
anesthetic if I have a known allergy to “caine” type
anesthetics such as benzocain, tetracain, xylocaine or
lidocaine. Serious skin reactions and rarely death due to a
severe allergy can occur
____Initials
Infrared Skin Tightening
During this procedure the
Infrared Device is gently brushed across a small area of
skin. After about 30 seconds the client will begin to feel
some discomfort as the skin heats up. We will ask you to
gauge your pain on a scale of 1-5 with 5 being very painful
and not tolerable. When the skin gets to a 4 or 4.5 level,
the client will indicate by saying “Now” and Dr. Christian
will remove the device for a few seconds and allow the skin
to cool down and then start the process again. We want to
heat up the skin to about a 4 level and keep it there for
about 30 seconds.
____Initials
Burning, Blistering,
Scarring, Swelling and Infection
The “Pixel” Laser,
Intense Pulsed Light and Infrared Skin Tightening work by
creating heat to damage the target lesion and hopefully
leave the normal tissues undamaged. Sometimes the target
lesions take up enough light and covert it to heat that
swelling or burning and then a blister will form. For this
reason, the initial treatment may be on the Conservative
side to evaluate how your skin will respond. If Dr.
Christian senses that my skin has been recently tanned, he
has the option of canceling a scheduled procedure for 3
weeks until the tan has subsided.
Please realize that a
sunburn type sensation with a little swelling is normally
seen for up to 2 days after these treatments especially in
aggressively treated areas and around the eyes. This can be
relieved to some extent with a 1% Hydrocortisone Steroid
Cream and Lanacaine Topical Cream, both available over the
counter. If blistering develops, I will contact Dr.
Christian and he will prescribe a treatment program to allow
for healing of the blister which may include antibiotics
especially if there is a suspicion of infection or that the
infection has spread to the blood (Very Rare). If untreated
the blister may become infected with poor healing or pigment
changes. Scarring is rare but can occur in individuals with
a history of Keloid formation or if a secondary infection
occurs. In some patients there can be activation of herpes
simplex (cold sores) or herpes zoster (Shingles) in and
around treated areas and I may need antiviral treatment to
hasten resolution.
____Initials
Bruising and Bleeding
The “Pixel” Laser and
Intense Pulsed Light can potentially can damage tiny blood
vessels in the upper dermis. This might lead to the
appearance of some bruising in the treated areas. Blood
vessels however are not the target for the “Pixel” Laser but
the Intense Pulsed Light is helpful for small red and blue
spider like vessels of the cheek, nose and chin. A small
bruise on the face will resolve in 7-10 days but on the body
may take 2-4 weeks or longer to resolve.
____Initials
Pigment Changes
If a blister forms or
some bruising occurs, the healing process may result in
either some increased pigmentation or decreased
pigmentation. This may last several months and slowly
improve or may be permanent. The use of post treatment
sunscreen can minimize this risk and in some cases bleaching
creams may be of additional benefit.
____Initials
Blindness or Eye Damage
The “Pixel” Laser,
without protective eyewear, may cause visual loss including
blindness. It is important to keep eye shields on at all
times during the procedure and I should keep my eyes closed
in order to protect my eyes from accidental exposure.
____Initials
Diamond Microdermabrasion
or Facials with Javani
We will perform 3 Diamond
Microdermabrasions with the Javani Procedure in conjunction
with these procedures to help hasten the removal of the
damaged epidermal layer and pigmented lesions which are
shedding. The side effects of these procedures consist only
of some mild redness and a slight sunburned or wind burned
feeling for about 12-24 hours after the procedure. Rarely
some bruising or serious irritation may occur.
____Initials
Operator
Your procedure for the
“Pixel” Laser, Intense Pulsed Light and the Infrared Skin
Tightening will be provided by Dr. Christian who has been
trained in laser science, use of the equipment, laser safety
and skin care.
____Initials
Safety
All standard safety
precautions will be followed to ensure the utmost safety
during your treatments. This includes the use of protective
eyewear at all times while the equipment is in use. We
recommend removal of contact lenses during facial
treatments.
____Initials
Long Term Risk
I understand that the long
term risks of the “Pixel” Laser for Skin Resurfacing,
Intense Pulsed Light and Infrared Skin Tightening may not be
fully known. Although considered safe and research studies
have shown these types of treatment to be useful for the
Indicated conditions, Inside Outside Wellness Center and
Medical Spa cannot be held responsible for any “Pixel” Laser
Skin Resurfacing, Intense Pulsed Light or Infrared Skin
Tightening risk not yet discovered or commonly known.
____Initials
Continued Consent
I agree that this consent
shall apply to all subsequent treatments of a similar
nature.
____Initials
Guarantee
I understand that although
every reasonable effort will be made to achieve a desirable
outcome no guarantees are stated or implied. If you incur a
complication which prohibits further treatments we will
refund your money.
____Initials
Photographs
I consent to the taking of
photographs prior to and during the period of treatment to
document the changes and any complications that might occur.
These photographs will be the property of Dr. Christian and
may be used for teaching and demonstration purposes and my
identity will not be revealed at any time.
____Initials
Physician Option to
Modify or Discontinue Program
Dr. Christian reserves the
option to modify the program at any time to achieve the best
results with the technology we have available. In addition,
Dr. Christian reserves the option to discontinue the program
at any time he feels the patient is not complying with the
directed skin care program or is having other procedures
done at another facility which may jeopardize this program.
I agree to inform Dr. Christian of new medicines or any new
procedures I am having performed on my skin.
____Initials
Post Procedure
Considerations: Important Information
Sun Exposure:
I realize that exposing the
treated area to the sun during the period of treatment will
potentially reverse some of the beneficial changes we have
achieved and may increase the risk of complications.
Immediately after the procedure and for a few days the skin
will have a mild to moderate sun burn feeling. Sun Exposure
during this period would make it worse and should be
avoided. I will not intentionally tan the treated areas
and I will always use the recommended sun protection (SkinCeutical
Daily Sun Defense SPF 20) if I go out in the sun, even on
overcast and rainy days. UVA radiation will penetrate
clouds and windows so protection is needed at all times.
____Initials
Care of Treated Skin Post
Procedure:
1. The “Pixel” appearance
of the treated skin will be visible until the layer of dead
epidermal skin sheds off and pigmented lesions will be
slightly darker. On about the 3rd day the dead
epidermal layer will feel a little “leather” like and then
start to slowly shed. Pigmented lesions should flake off by
the 7th day.
2. I will clean my skin
twice daily with a gentle cleanser and not attempt to pick
at or peel off the dead epidermal layer or the pigmented
lesions which are shedding. I will let this layer of dead
skin and the pigmented lesions come off naturally. I
realize that removing this shedding layer or the flaking
pigmented lesions prematurely may lead to an underpigmented
area which may be much different from the surrounding skin,
especially if my skin has some natural pigment in it.
3. The ‘Pixel” appearance
may be concealed to some extent with make up or foundation
but in some cases it actually makes the “Pixel” appearance
more exaggerated. Simply keeping the skin hydrated with
Javani Cream, B-5 Hydrating gel or applying the 1%
Hydrocortisone Cream will tend to minimize the “Pixel”
appearance.
____Initials
Blistering: If a blister
develops, I will notify Dr. Christian for instructions on
how to care for it.
____Initials
Followup Visits:
I understand Dr. Christian may ask me to return for a short
visit 1-3 days after my procedures to check on my skin and
the results of the procedure. These visits are important as
they give Dr. Christian a better idea of the settings to use
at my next session. If Dr. Christian asks me to return for
a short followup visit I will do so and not make him chase
me down.
____Initials
I certify that I am a
competent adult of at least 18 years of age.
Minors (under 18 years of
age) require additional consent form a parent or legal
guardian.
____Initials
Importance of On Time
Appointments
I will do my best to be on
time for the appointments. There is much to do in the hour
allotted for the treatments. I realize that it is not safe
to have Dr. Christian rushed through a “Pixel” Laser
treatment. If you are over 15 minutes late we may decide to
reschedule the procedure.
____Initials
My signature attests to the
fact that I have fully read this entire Consent and
Disclosure form, that I have had any concerns answered to my
satisfaction, that I understand the information contained
within, and accept the risks inherent in “Pixel” Laser Skin
Resurfacing and/or Infrared Skin Tightening Treatments.
I hereby consent to proceed
with the ‘Mini” Non-Invasive Extreme Makeover consisting of
3 Diamond Microdermabrasions with Javani Procedure, “Pixel”
Laser Skin Resurfacing, Intense Pulsed Light and Infrared
Skin Tightening Treatments.
In understand the areas to
be treated are the Face for the Intense Pulsed Light,
‘Pixel” Laser and Diamond Microdermabrasions. The Neck,
Cheek and Jowls will be treated with Infrared Skin
Tightening.
If I desire other areas to
be treated there will be an additional charge.
Please Initial other
Area(s) to be treated.
Neck “IPL”: _________
Neck “Pixel”: __________
Hands “IPL”: _________
Hands “Pixel”: __________
Chest “IPL”: _________
Chest “Pixel”: ________
Other, Identify:
_______________________
Date: _______________
Signed:
___________________________
Printed Name:
_________________________
Parent/Legal Guardian for
Patient under 18: _____________________________
Download this Consent and Disclosure in a .doc format
