I authorize Dr. Zimmerman/Dr. Lee and staff to perform fractional non-ablative laser resurfacing on my skin in an effort to improve Dyschromia / Periorbital Wrinkles / Acne Scars / Surgical Scars / Striae / Other skin condition.
Pre and post-care instructions have been discussed and are completely clear to me.
I understand that there is a rare possibility of side effects or serious complications post treatment, including pigmentary changes and scarring. I am aware that careful adherence to all advised instructions will help reduce this possibility.
I understand that sun exposure or tanning of any sort is not aligned with the pre and/or post-care instructions and may increase the chance for complications.
The procedure as well as potential benefits and risks have been thoroughly explained to me and I have had all my related questions answered.
I understand that results may vary with each individual and acknowledge that it is impossible to predict how I will respond to the treatment and how many sessions will be required for the expected level of improvement.
I consent to photographs being taken for the purpose of documenting my progress and response to the treatment and be kept solely in my medical record.
I consent to photographs being used for medical education or publication with applied discretion and not revealing my identity.
I agree to review the laser pre-treatment compliance checklist below along with my Physician and bring accurate and updated data, to the best of my knowledge.
I understand the below list of short-term effects and skin responses and agree to follow matching guidelines:
Discomfort – during the procedure, I might experience a hot needle pricking sensation which degree will vary per my skin condition and area sensitivity. A mild “sun-burn” sensation may follow for typically up to one hour and will be reduced with application of cooling and soothing creams.
Reddening and swelling – severity and duration depend on the intensity of the treatment and the sensitivity of the area to be treated. These phenomena may be reduced with application of cooling and/or anti-inflammatory creams.
Xerosis and pruritus - within the first few days after treatment, my skin may feel itchy, tight and dry. Regular application of moisturizers helps reducing this sensation.
“Bronzed” appearance - within the first few days after treatment, I may develop a pinkish and/or coloured tone and discrete dry flaking. It is important I do not rub nor pick my skin which may otherwise lead to scarring. A broad spectrum (UVA/UVB) sunscreen SPF 30 or greater should be applied to the area(s) to be treated whenever exposed to the sun.
Please answer the following questions to the best of your abilities:
My signature certifies that I have duly read and understood the content of this informed consent form and gave the accurate information as to my health condition. I hereby freely consent to ResurFX™ laser treatment.