This form is designed to provide you with information to help you make an informed decision about whether to have this treatment performed. It is intended to educate, not scare you. If you have any questions at any time or do not understand any potential risks, please ask for an explanation.
The treatment uses a combination of Intense Broad Spectrum Light and suction to lighten, fade or remove non-cancerous, flat, pigmented lesions and superficial, vascular lesions over a series of sessions. It is also used for long-term hair modification. Light wavelengths, pulse duration, pause and energy levels are chosen to selectively and maximally be absorbed by the targeted pigment while causing minimum damage to the surrounding skin. The top layers of the skin are further protected with evaporative cooling. Other treatments and skin regimes may be recommended which compliment FotoFacial™ and FotoBody to obtain optimal results.
PLEASE INITIAL NEXT TO EACH PARAGRAPH TO SIGNIFY YOUR UNDERSTANDING.
You will be asked to complete a history including current medications/herbs/elixirs and vitamins you have taken recently; whether you have tanned the treatment area in the past month or are intending to do so and what previous treatments and results you have had. A test area may be recommended to help determine the best parameters for you. Darker skinned patients will sometimes have to pre-treat their skin with bleaches and sun blocks to obtain better results with less risk.
On the treatment day, after your skin is cleansed of all makeup and sun block, a topical anesthetic, which takes about 30 minutes to take effect, may be applied to very sensitive areas, but usually no anesthesia is needed! You will be given special glasses or plastic shields to protect your eyes. The treatment area is thoroughly moistened. The treatments feel like a series of very quick skin pulls and zaps or warm tingles compared to other Intense Pulsed Light systems. After the treatment, your skin will be slightly red and pigmented and vascular lesions will darken temporarily. Over several weeks they will dry up or contract further and you will be scheduled for a re-check or your next treatment in 3 to 6 weeks. You may notice that your skin becomes smoother and slightly tighter over a number of treatments.
Clinical results may vary for patients with different skin colors. The easiest patients to treat have light skin that does not compete for the light or radio wave energies and darker pigmented lesions, blood vessels and hair which, aggressively absorb those energies. The closer the skin and lesion color, the lower the settings have to be to protect the skin and the more treatments it can take to achieve the desired results.
Treatment of vascular and pigmented lesions may result in hair loss/thinning in those areas that can cause a feminizing appearance in some men. Treatment of haired areas may result in pigmented and vascular lesions lightening in those areas. Please warn us if there is a special “beauty mark” that we should avoid treating.
Short-term side effects include skin reddening, mild burning, blisters, superficial scabs, temporary bruising, tissue swelling and discoloration of the skin. Rare side effects such as scarring and permanent skin lightening or darkening may also occur. Side effects happen most often when you unintentionally take a medication that sensitizes your skin to the light energy. Certain antibiotics, heart and depression medications and some herbal remedies are sun sensitizers. Taking Ginkgo, Garlic, Ginger, and Vitamin E, Aspirin or other similar medications may thin your blood and predispose you to bruising from the treatment. Vitamin C and K help you to avoid this. If you are uncertain about any medications or products you are taking or using please ask the office.
These products should not be used by people who have experienced hypersensitive allergic reactions to them previously (we see about 1 allergic skin test every 2 years) or who know they are allergic to cow collagen injections. It can not be injected into areas that have active inflammation or infections (e.g.: active acne, cysts, rashes and hives)
Other treatments for benign skin lesions include freezing them, treating them with various wavelength of lasers, radiofrequency, electro-surgery or even excision with a scalpel. Vascular lesions above the waist can be injected with sclerosants if they are larger. They can also be treated with radiofrequency, electro-surgery or certain lasers. Long-term hair reduction can be achieved with electrolysis, lasers and intense pulsed light without radiofrequency energy. All these options have pros and cons to them, which we can discuss further at your request.
Another option is to receive no elective treatment at all for your cosmetic condition. Your condition may progress over time if you do nothing.
I have been fully informed of the nature and purpose of the procedure, expected outcomes and possible complications. I understand that medicine is not an exact science and therefore reputable practitioners cannot guarantee exact results. I am fully aware that my condition is a cosmetic concern and that the decision to proceed with this elective procedure is based solely on my expressed desire to do so.
I hereby authorize Dr. Edward Zimmerman/Dr. Lee and/or staff to apply topical numbing creams that contain anesthetics like you may have had injected by your dentist. Please tell us if you have ever had a problem with topical or injectable anesthesia.
Please initial your understanding by each line:
Treatments should NOT be done if you are pregnant. I am not pregnant at this time and will alert you if that changes.
I have not taken Accutane within the last six months
I confirm that I am not taking any medications that cause sun sensitivity or bruising and will inform the office if this changes during the course of my treatments.
I consent to photographs to monitor improvement of my condition with progressive treatment and authorize their anonymous use for the purposes of medical education and promotion.
I agree to keep the office informed of any changes in my medical conditions, address or phone numbers to insure my safety, best results and future recommendations.
By signing below, I acknowledge that I have read the foregoing informed consent form and that I understand the risks of the treatment, alternative methods of treatment, and the risks of not treating my condition. I freely that request Dr. Zimmerman/Dr. Lee and/or his staff perform these treatments.
I have been given the opportunity to ask questions and had them fully answered to my satisfaction.