This form is designed to give you the information you require to make an informed choice of whether or not to undergo treatment with LUMECCA™/IPL technology. If you have any questions before your treatment please feel free to ask.
• I hereby authorize Dr. Elijah and/or such assistants as may be selected to perform the LUMECCA™/IPL procedure.
• The physician obtained my medical history and found me eligible for treatment
• I have received the following information about the technology:
o LUMECCA™/IPL is a non-invasive IPL (Intense Pulse Light) technology that utilizes the technology for Skin Rejuvenation, Pigmented and Vascular lesions improvement.
o Pigmented lesions will become darker for a period of 1-2 weeks before starting to lighten. Local inflammation around the lesions, manifested as some redness and swelling may accompany the response, as part of the healing process.
o Blood capillaries will clot and appear darker for 1-2 weeks before disintegration. Some redness and swelling may accompany the response, as part of the healing process.
o Some skin tightening may occur immediately, which may decline for 1-2 months, but will improve then, as new collagen fibers are produced.
o All 3 lesions: brown, red and loose skin may improve simultaneously.
o No complete clearance is guaranteed
o Treatment requires a number of sessions
o Exact number of sessions is individual
o There may be some discomfort and transient redness and/or swelling associated with treatment
o There is a small risk of adverse reactions
• I understand that taking the treatment course is my choice and that I am free to withdraw at any time, without giving any reason
• I was told about the possible side effects of the treatment including: local pain, skin redness (erythema), swelling (edema), damage to the natural skin texture (crust, blister, burn), change of pigmentation (hyper- or hypo-pigmentation), and scarring. Although these effects are rare and expected to be temporary, any adverse reaction should be reported immediately
• I understand that I have to comply with treatment schedule, otherwise results may be compromised
• I recognize that during the course of the procedure unforeseen conditions may necessitate different procedures than this above and I authorize the physician or assistants to perform such other procedures if they find them professionally desired
• I understand that not everyone is a candidate for this treatment and results may vary therefore, there is no guarantee as to the results that may be obtained