PhotoFacial/IPL Consent


The purpose of treatment is intended for photo rejuvenation, and improvement of benign vascular and pigmented lesions. The procedure requires more than one treatment.  The total number of treatments will vary between individuals. On occasion, there are those that do not respond to treatments. There are several alternatives to treatment, including but not limited to, other laser treatments, chemical peels, microneedling, or no treatment at all.

The following risks may occur with treatment. However slight, there is a risk of scarring, pain, bruising, swelling, redness, itching, skin inflammation or irritation (dermatitis), allergic reaction, blistering, hypopigmentation, hyperpigmentation, mottling of skin vascularity and pigmentation, and other unforeseen complications. These conditions usually resolve in 3-6 months, but permanent color change is a risk. Avoiding sun exposure before and after the treatment reduces this risk. Infection following treatment is unusual; bacterial, fungal and viral infections can occur. Herpes simplex virus infections around the mouth can occur following a treatment. This applies to both individuals with a past history of herpes simplex virus infections, and individuals with no known history of herpes simplex virus infections in the mouth area. Should any type of skin infections occur, additional treatments or medical antibiotics may be necessary.

In rare cases, local allergies to topical preparations have been reported. Systemic reactions, which are more serious, may result from prescription medicines. I understand that exposures of my eyes to light could harm my vision and eye protection goggles provided on at all times. Compliance with the aftercare guidelines is crucial for healing, prevention of scarring, and pigment changes. Occasionally, unforeseen mechanical problems may occur and your appointment will need to be rescheduled. We will make every effort to notify you prior to your arrival to the office.

I have been advised of the risks of treatment, the expected benefits, and alternative options, including no treatment at all. I have been given the opportunity to ask questions about my condition and the treatment and alternative forms of treatment. I understand that every effort will be made to provide a positive outcome, but there are no guarantees of results. I understand and accept the risks of the procedure, and request that it be performed on me. I hereby release the medical director, esthetician, and facility from liability associated with this procedure. I consent to this procedure today and for all subsequent treatments.

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Signature Certificate
Document name: PhotoFacial/IPL Consent
lock iconUnique Document ID: c173daa75ee0dcd6711fecbd9f1ca08716fc6246
Timestamp Audit
May 20, 2020 8:13 pm PDTPhotoFacial/IPL Consent Uploaded by Skinlogic Med Spa - infossc2001@gmail.com IP 173.160.193.254