Laser consent form
Martin Braun III, M.D.
Alicia Braun, M.D
Martin Alan Braun, M.D.
Marisa Braun, M.D.
2112 F Street, N.W. Suite 701
Washington, D.C. 20037
INFORMED CONSENT FORM FOR LASER THERAPY
I understand that the ND-Yag / pulsed dye / Cynergy-Multiplex laser is being used for the treatment of ____________________ under the direction of ___________________. Although laser therapy is safe and effective in the majority of cases, unexpected adverse events may occur. Unexpected side effects may result from the use of the laser, and the expected response of the treated area may not be achieved.
______ 1. Short term effects:
I understand that there are multiple short term effects that
may occur with laser therapy, including reddening, irritated raised rash, mild burning,
swelling, bruising, numbing, temporary pigmentary change, blistering, scabbing,
crusting, flaking, and sensitivity to the sun. Although these effects typically resolve
within several days, they may persist for several weeks and rarely, even longer. I
understand that the degree of the side effects varies from person to person, and it may not
be possible to predict how I will respond.
______ 2. Possible permanent effects:
I understand that although most side effects are
short term and resolve fairly quickly, some effects may be permanent. Scarring and
changes in pigmentation (lighter skin or darker skin) may be permanent.
______ 3. Discomfort associated with procedure:
I understand that the laser functions
by heating up its target (blood vessels, pigmentation). This heating sensation is
minimized by the use of the cooling air, but some level of discomfort may be felt. The
level of discomfort depends on the treatment being done, and varies from person to
person. The stinging or sensation of heat is typically short term but may persist for
several hours after the procedure.
______ 4. Effects of UV:
I understand that sun exposure, tanning beds, sunless tanning
lotions, and tanning creams can cause discoloration or reaction to laser treatment during
and after the procedure. Having any kind of tan prior to therapy or soon after therapy
results in an increased chance of blistering, permanent or temporary discoloration,
scarring, and discomfort. I understand that avoidance of any UV exposure 1 month prior
and 2 weeks after treatment reduces the risk of these effects.
______ 5. People excluded from therapy:
I understand that certain patients should not
have laser treatment. This includes any patients who have open wounds, malignant skin
tumors, patients who have certain disease that make them sensitive to light, patients
currently on Accutane or who have been on Accutane within in the last 3 months, and in
many cases, patients who have tattoos in the area to be treated.
______ 6. Need for multiple treatments:
I understand that many conditions being
treated by the laser will require multiple treatments to obtain the desired results. For laser
hair removal, the procedure works by targeting growing hair follicles, not dormant hair.
Complete destruction of all hair follicles with a single treatment is therefore not possible,
and multiple treatments are necessary. For redness/rosacea, results are seen after the first
treatment, but multiple treatments are often necessary to remove the desired amount of
redness/blood vessels, and multiple treatments are often necessary to smooth a blotchy
appearance that may be present after 1 treatment. Everyone responds in different ways
and different rates to the treatment.
______ 7. Tattoo/permanent makeup:
If there are any tattoos or permanent makeup in
the area, there is a possibility of blistering and lightening of the tattoo/makeup.
______ 8. Photographs:
I understand that the physician may choose to take photos of
my treatment area for the purpose of monitoring my progress.
______ 9. For laser hair removal:
I understand that there are other options for laser hair
removal such as electrolysis, waxing, and chemical preparations. I understand the
difference between these options and laser hair removal, and I am choosing laser as a
noninvasive treatment for my hair epilation. I also understand that the hair follicles that
are treated are permanently destroyed, and may not grow back (this is especially
important when treating certain areas such as the neck, beard/moustache area, scalp). Use
of the laser is FDA cleared for permanent hair reduction, and it is possible that new hairs
will grow at some point in the treated areas. Response to treatment varies from patient to
______ 10. For laser vein treatment:
I understand that this procedure involves a laser to
coagulate the vessels and a bruising effect could last up to 6 months. It is possible the
results will be minimal or not help at all. I realize that each individual’s treatment
response is different; therefore it could require multiple treatments to achieve desired
results. Other options are available, and may include sclerotherapy and surgery.
______ 11. For non-ablative LaserFacial:
I understand that erythema (redness) is a
common immediate reaction from the LaserFacial treatment process. This typically
resolves in 2 hours, but may last longer. I understand that 4-6 treatments are required for
the non-ablative LaserFacial to be most effective, and it is important to follow the
recommended maintenance schedule for future treatments to keep the best possible results. I also realize that each individual’s treatment response may be different, and the number of treatments may vary to achieve desired results.
______ 12. For laser treatment of redness/rosacea:
I understand that this procedure for
reduction or elimination of redness/telangectasia/rosacea could result in a bruising effect
that could last 2-3 weeks. It is possible that the results will be minimal or not help at all.
Each individual’s treatment response is different; therefore it could require multiple
treatments to achieve the desired results.
______ 13. I understand that my insurance company will not cover the cost of laser therapy, and I am responsible for the complete cost of the service. Payment is due at the time of the treatment. I also understand that once I have started my treatment program, there are no refunds.
______ 14. I have received, read and understand the post-treatment instructions.
Dr. Braun has explained the nature and purpose of the laser treatment, including any risks and possible complications, and has discussed the contents of this form with me. I have read and understand this consent form, and I agree to its terms and authorize treatment. I further understand that Dr. Braun cannot guarantee the results. I will not hold Dr. Braun or his/her employees responsible for my individual results.
Patient name (printed) _______________________________________________________________ Patient Signature: _____________________________________
(Parent or guardian if patient is under 18)
Date: _________________ Physician signature ___________________________
Witness signature ______________________
MEDICATION DEFERRAL LIST Please tell us if you are now taking or if you have EVER taken any of these medications: Proscar© (finasteride) usually given for prostate gland enlargement Avodart© or Jalyn © (dutasteride) usually given for prostate enlargement Propecia© (finasteride) usually given for baldness Accutane© (Amnesteem, Claravis, Sot
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