FotoFacial™ Intense
Pulsed Light Treatment Consent
The
purpose of FotoFacial™ treatments is to improve the appearance and
texture of the skin. The treatments use pulses of intense filtered
light. I have been informed of the types of problems that may be
improved by these treatments. The goals of treatment are to reduce
redness, flushing, fine spider veins and the symptoms of Rosacea.
They remove or reduce abnormal skin pigment. And they improve skin
texture, soften fine wrinkles and reduce roughness and pore size.
I understand that FotoFacial™ treatment is a process with a minimum
of five treatments given at three-week intervals. Some patients may
need additional treatments in order to achieve their goals or maximal
improvement. I understand that the response may vary and there is no
guarantee of the amount of improvement I will achieve. Some conditions
may reoccur and require touch-up treatments.
Initial ____
I understand that there are contraindications that include pregnancy,
medications that cause light sensitivity, keloid tendency, anticoagulant
use, and bleeding disorders. I also understand that recent tanning
may result in adverse reactions and treatments must be delayed until
the tan is gone.
Initial ____
I understand that there are common side effects with may be expected
with treatments. These include pain with treatment flashes which is
usually mild, redness lasting one to several days, visible vessels
will be more apparent after treatment, abnormal pigment spots will
darken for several days, swelling and occasionally welts that may last
for several days.
Initial ____
Complications that are unlikely but possible include superficial darkening,
crusting or blistering of the skin; temporary darkening or lightening
of the skin that may take weeks to months to clear. Permanent adverse
results such as visible scarring or permanent light spots are very
rare but possible. Infrequently, pulsed light treatments may result
in the activation of herpes virus infections or cold sores.
Initial ____
I understand that the results of FotoFacialTM treatment are affected
by how I care for my skin both before and after treatments. This includes
proper sun protection and may include following a skin care regimen
appropriate for my skin.
Initial ____
FotoFacialTM intense pulsed light treatments can result in temporary
or permanent hair loss in the treated area. Care will be taken to reduce
the chance of undesired hair loss by shielding it. I understand that
if areas containing hair are treated it may result in full or partial
hair reduction that may be permanent.
Initial ____ I understand that FotoFacialTM is not a treatment for skin cancers
or pre-cancers. It is not primarily for the treatment of deep wrinkles
and is not a substitute for a face-lift or laser resurfacing. I understand that FotoFacialTM treatments are cosmetic and not covered
by insurance. I understand that I am responsible for all costs of treatment.
Initial ____
I authorize the taking of clinical photographs of me for clinical documentation
and for educational purposes. I understand that any photo used for
patient education or other professional use will be anonymous and have
no information identifying me.
Initial ____
I have received information on alternatives to treatment and all my
questions have been answered to my satisfaction. I understand that
FotoFacialTM and intense pulsed light treatments have risks from both
known and unknown causes. These include but may not be limited to those
described above. I freely assume these risks and authorize Dr. Paul
Van Camp MD, Johane Van Camp PAC, and/or staff to administer Intense
Pulsed Light or FotoFacial treatments on me.
Patient Name__________________
Patient Signature__________________
Witness Signature__________________
Date __/__/__
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