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Lake Pointe Women’s Aesthetic Centre
6900 Scenic Dr., Suite 100
Rowlett, TX 75088
(972) 475-7555
Intense Pulsed Light (IPL) Photo Rejuvenation Consent and Disclosure Form
Mechanism
The IPL system produces a broad beam of highly concentrated light. This light is filtered
to a wavelength that is selectively absorbed by the target tissues with minimal effect on
surrounding tissues. This absorption produces heat, which in turn destroys the
undesirable target tissues. The body’s natural healing process then absorbs the damaged
tissue and allows for regrowth of healthy tissue. The duration (milliseconds) and energy
(fluence) of the light pulse are adjusted for your specific skin characteristics to achieve
maximum benefit. The target is usually abnormal pigmentation or small, unsightly blood
vessels.
Operator
Your care will be provided by our Nurse/Aesthetician who has been trained in laser
science, use of the equipment, laser safety, skin care and other necessary areas of
knowledge. Required oversight by a licensed physician is adhered to and the Lake Pointe
Women’s Centre medical director is available to address any concerns that you may have.
Safety
All standard safety precautions and all IPL specific guidelines will be followed to ensure
the utmost in safety during your treatments. This includes the use of protective eyewear
at all times while the equipment is in use. We recommend removal of contact lenses
during facial treatments.
Alternatives
_____ I am aware of alternative methods of treatment such as topical chemical products
and other light-based or laser systems. I realize that various other alternative services
may be available through skin care specialists. I understand that my concerns regarding
the condition of my skin may be caused by various medical conditions that may require
other forms of treatment and that it is my responsibility to explore such options prior to
IPL therapy. I have explored these other options to my satisfaction and have made an
independent decision to proceed with IPL Photo Rejuvenation treatments.
Limitations
_____ I understand that some rejuvenation is achieved in nearly everyone, but that
complete rejuvenation may not occur. Results are limited by the equipment capability as
well as personal skin and hair characteristics. My Fitzpatrick skin typing has been
analyzed, and I understand that a higher Fitzpatrick typing increases the potential risk of
the treatment. Hormonal therapy and other medical conditions may affect my results.
These issues will be discussed at the time my medical history is reviewed. Results are
cumulative; therefore a series of treatments is necessary to achieve maximum benefit.
Actual results cannot be guaranteed.
Cautions
_____ If I am subject to keloid formation, excessive scarring or poor healing
(uncontrolled diabetes or other conditions) I will consult my personal physician prior to
proceeding.
_____ I will avoid sun tanning, tanning booths and tanning creams for at least 4 weeks
prior to and after treatments as this will reduce the effectiveness and increase side effects.
_____ I understand that Accutane (or similar products containing tretinoin) should not be
used for 6 months and Retin-A (or similar products containing isotretinoin) should not be
used for at least 2 weeks prior to treatment.
_____ I will not use glycolic acid or other alpha hydroxyl acid products for 3-5 days
prior to and 5 days after a treatment.
_____ I understand that treatments cannot be done on skin areas with open sores or
lesions.
_____ I understand that tattoos and permanent makeup may be altered and that moles
may be lightened.
_____ I understand that recurrent viral infections such as herpes simplex (cold sores) or
varicella (shingles) may be activated and that hair growth in the treated area may be
affected.
_____ I also understand that pregnant/lactating women should not be treated.
_____ If I have a personal or family history of skin cancer, I have been advised to
consult a specialist before having pigmented lesions treated.
_____ Prior to any treatment, I will advise Lake Pointe Women’s Centre of any historyof excessive bleeding or bruising, if I am taking an anticoagulant (blood thinning)medication (including aspirin), if I have sun sensitivity or am using any sun sensitizingmedications, hormones, steroids, Accutane, Retin-A or similar products, orcontraceptives.
_____ I agree to provide Lake Pointe Women’s Centre with an accurate personalmedical history prior to treatment.
_____ I understand that all reflective objects, such as jewelry and watches, must beremoved if near the treatment area.
Discomfort
_____ I understand that the sensation generated by the light pulse is most commonly
described as a rubber band snapping against the skin, and most individuals are able to
tolerate this sensation for the short duration of the treatment.
_____ I understand that I may have a sunburn type sensation in the treatment area for
several hours afterward.
_____ Topical anesthetics are available to decrease any perceived discomfort from the
IPL treatment. If I desire a topical anesthetic, I will discuss this with my IPL technician.
Pre and Post Treatment Instructions
_____ I acknowledge receipt of pre and post treatment instructions. I understand that
failure to follow these may affect my treatment outcome and increase the likelihood of
severity of complications.
Skin Changes
_____ I understand that I may experience temporary redness similar to sunburn. Some
skin swelling may occur. Blistering, scabbing, infection and other skin changes are alsopossible, although much less likely. I understand that in most cases, all of these effectsshould resolve over the next several hours to days following treatment. I understand thatcold compresses and aloe vera products may be beneficial, and in extreme cases a mildsteroid cream or antibiotic may be necessary. Scarring is extremely rare and usuallyoccurs in those with a predisposition such as a history of keloids or other excessivescarring, but acknowledge that scarring is possible with any patient. I have been advisednot to undergo IPL treatments if I have such a history and under these circumstancesacknowledge that Lake Pointe Women’s Centre cannot be responsible for the outcome ofmy treatments. I agree to carefully follow the post treatment instructions to reduce thelikelihood or severity of any skin changes.
Pigment Changes
_____ I understand that hypopigmentation (decreased skin coloration) or
hyperpigmentation (increased skin coloration) is uncommon, but if it occurs to me,
although rarely permanent, may last several weeks to months. I understand that post
treatment use of sunscreen is advised to minimize the risk, and that in some cases
bleaching creams may add additional benefit.
Long Term Risk
_____ I understand that the risks of IPL use may not be fully known. The information
presented to me is based on recent studies conducted over a relatively short period of
time. Although considered safe, Lake Pointe Women’s Centre cannot be held responsible
for any IPL risk not yet discovered or commonly known.
Continued Consent
_____ I agree that this consent shall apply to all subsequent treatments of a similar
nature.
Guarantee
_____ I understand that although every reasonable effort will be made to achieve a
desirable outcome, no guarantees are stated or implied.
My signature attests to the fact that I have fully read this entire consent form, that I havehad any concerns answered to my satisfaction, that I understand and agree to theinformation contained within, and accept the risks inherent in undergoing this procedure.
I hereby consent to the use of the Intense Pulsed Light (IPL) system in the hopes ofattaining the desired beneficial results.
___________________________________________________________ _______________________________________________ ___________________________________________________________ _______________________________________________ Parent/Guardian Signature (if under age 18) ___________________________________________________________ _______________________________________________ Name____________________________________ Date ofBirth___________________________

Source: http://lpwc.net/images/aes_forms/Photo_Rev_Consent.doc.pdf