Consent - Laser Facial

Simply Skin Las Vegas

Client Care Treatment Instructions - Laser Facials/Acne/Resurfacing
Name*

First NameLast Name
PRE-TREATMENT INSTRUCTIONS
- You MUST cease all bleaching, plucking/tweezing, waxing, threading/stringing, and electrolysis for 4 weeks prior to treatment.
- You may be asked to stop any topical medications or skin care products prior to treatment
- Avoid sun exposure and sun bed for 2 weeks prior to treatment. RECENTLY SUN EXPOSED SKIN CANNOT BE TREATED. If treated within two weeks of active (natural sunlight or tanning booth) tanning, before or after treatment, you may develop burns that heal in hypo pigmented white spots, and this may not clear for 2-3 months. In extreme cases, this may be permanent
- The use of self-tanning products/bronzers must be discontinued one week before treatment. Any residual self-tanner must be removed prior to treatment
- Shave the area to be treated one day prior to treatment with a fresh razor
- If you have had a history of perioral or genital herpes simplex virus, antiviral therapy is recommended in order to prevent a breakout. Follow the directions for your particular antiviral medication
- The treatment area should be clean of any perfume, deodorant, makeup, lotions, sun block, or any other chemical or skincare products
INTRA-TREATMENT CARE
- At the beginning of every treatment session, we will review your medical status, and ask if there have been any changes. Please remember to inform us of any changes such as health, medications, and sun exposure. Changes may alter the effectiveness of treatment and may cause side effects and/or complications
- The skin is cleaned prior to treatment
- The technician may line the area with a white pencil in order to effectively treat you. This will wash off
- When treating the upper lip, the teeth can be protected with white gauze. The gauze also serves to support the lip during treatment allowing a surface to push against
- Safety considerations are important during the laser procedure. Protective eyewear must be worn during the procedure
- Some clients may feel a slight discomfort or pain after treatment sometimes described as an intense heat like a sunburn with excessive hyperpigmentation and/or redness and possible swelling.
POST-TREATMENT INSTRUCTIONS
- Immediately after the treatment, there may be swelling and redness in the areas that are treated. The redness may last up to 2-3 days. It is normal for the treated area to feel like sunburn for a few hours after treatment. You should use a soothing gel that is available in our salon in conjunction with a cold compress (not frozen, but cold), aloe gel, or topical hydrocortisone. An antihistamine may be used as well. Please be mindful that some antihistamines may cause drowsiness and should be avoided if driving or operating heavy machinery. If any crusting, apply antibiotic cream. Patients with darker pigmented skin may have more discomfort than those with lighter skin, and may require the aloe gel or an antibiotic ointment longer
- Treat blistered or ulcerated skin with a prescribed antibiotic ointment or burn treatment cream
- For 48 hours please avoid any activity that will raise body heat. No strenuous activities, no hot tub, steam room, sauna
- Please do not scrub or exfoliate the skin
- Keep your skin clean to avoid infection
- There are no restrictions on bathing except to treat the skin gently for the first 24 hours as if you have a sunburn, and to use cool water. The treated area may be washed gently with a mild soap. Skin should be patted dry and NOT rubbed.
- Wait 12-hours to use a skin cleanser. Make up can be applied 24 hours after treatment unless there is skin irritation or blistering. It is recommended to use new makeup to reduce the possibility of infection. Make sure that you have moisturizer on under your makeup. Frequent use of moisturizer is encouraged. Please make sure the moisturizer used does not have alpha-hydroxy acids, retinols, benzoyl peroxide or astringents
- Avoid sun exposure for two months to reduce the chance of dark or light spots. Use sunscreen SPF 30 or higher at all times throughout the treatment and for 1-2 months following
- Avoid tanning of any sort during the entire course of treatment.
- Avoid picking or scratching the treated skin. During your treatments, DO NOT exercise any other facial, skin rejuvenation, CO2, IPL, Laser, or any other methods or products on the treated area.
- NO waxing, NO threading/stringing, NO sugaring, NO plucking/tweezing, NO depilatory creams (nair, veet, etc.). ONLY shaving, if necessary, please to avoid excess irritation
- Please do not hesitate to call or text us at (702) 823-0852 if you have any questions or concerns
ACKNOWLEDGMENT: I acknowledge that I have had the opportunity to review the Client Care treatment Instructions prior to treatment.*

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Client Signature
If minor, Parent/Legal Guardian Signature

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Simply Skin Las Vegas

Client Consent, Rights, Responsibilities
We are committed to serving you with compassion, care, skill, and respect. As one of our clients, you have choices, rights, and responsibilities.
Client's Name*

First NameLast Name
I hereby authorize Simply Skin Las Vegas, its employees/agents/clinicians to perform acne treatments on me. Treatment sites include face, forehead, mono-brow, sideburns, lip, chin, ears, neck, arms, hands, fingers, thighs, legs, feet, toes, chest, abdomen, shoulders, back, buttocks.

The purpose of this procedure is to diminish or remove acne and/or acne scars an overall quality of the skin. I understand that I may require several treatments to obtain a significant, long-term effective. The total number of treatments will vary between individuals. I understand that genetics, hormones, medication, diet, allergies, and color of lesions may interfere with the treatment, and there are patients that may not respond at all, and/or patients – whose acne may come back.

I understand that the treatment is purely elective, and I hereby consent to be a patient receiving treatment. Alternative methods exist. I understand that certain complications are rare, but possible.
Other potential risks include itching, blistering, burns, infection, scabbing, and failure to achieve desired result.
The procedure may result in the following side effects or adverse experiences, and may carry some risks
- DISCOMFORT – Some discomfort may be experienced during treatment
- REDNESS/SWELLING/BRUISING – Short-Term/temporary redness (erythema), swelling (edema), and/or mild sunburn-like effects of the treated area is common and may occur. There also may be slight bruising.
- SKIN COLOR CHANGES – I understand that immediately post treatment, my skin will become darker, and will eventually crust. The crust will shed on its own. I UNDERSTAND THAT I SHOULD NOT PICK IN ORDER TO AVOID SCARRING. There is a possibility that the treated area may become either darker (hyper-pigmentation) or lighter (hypo-pigmentation). These conditions usually resolve within 3-6 months, but permanent color change is a rare risk. Compliance with the aftercare guidelines and avoiding sun exposure before and after the treatment reduces the risk of color change.
- WOUNDS – Treatment can result in burning, blistering, or pinpoint bleeding of the treated areas. If any of these occur, please contact our office immediately.
- INFECTION/BREAKOUTS – Infection is a possibility whenever the skin surface is disrupted, although proper wound care should prevent this. If signs of infection such as pain, heat, or surrounding redness develop, please call our office immediately. If you have had a history of perioral or genital herpes simplex virus, antiviral therapy is recommended in order to prevent a breakout. Follow the directions for your particular antiviral medication.
- SCARRING – Scarring is a rare occurrence, but it is a possibility if the skin surface is disrupted. To minimize the chances of scarring, it is IMPORTANT that you follow all post-treatment instructions provided by your healthcare staff. Compliance with the aftercare guidelines and avoiding sun exposure before and after the treatment reduces the risk of scarring.
- PARADOXICAL HAIR GROWTH – In rare occasions, stimulation of terminal hair growth following laser hair removal can occur within or adjacent to the treated area
- ALLERGIC REACTIONS – In rare cases, local allergies have been reported.
- EYE EXPOSURE – Protective eyewear (shields) will be provided. Exposure of the laser to the eyes could harm vision. It is important to keep these shields on at all times during the treatment in order to protect your eyes from accidental laser exposure.
I am aware of the possible complications/risks involved with the procedure and subsequent healing period. *

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I fully understand that it is impossible to make guarantees regarding the outcome of any cosmetic/medical treatment and/or procedure. I understand that clinical results may vary depending on individual factors, including but not limited to medical history, skin type, patient compliance with pre- and post- treatment instructions, and individual response to treatment. I acknowledge that no guarantees, either expressed or implied have been made to me regarding the outcome of any treatments and/or procedures. *

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I understand that I am financially responsible for all amounts due for services rendered at the time of the treatment. I also authorize the release of information to a licensed physician of the facility’s choosing for the purposes of professional interpretation and establishment of treatment recommendations.*

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I understand that my procedure may involve a series of treatments*

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I am fully aware that my condition is of cosmetic concern and that the decision to proceed is based solely on my expressed desire to do so.*

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I HAVE THE RIGHT TO:
- Be treated with dignity and respect
- Know the name(s) and professional status of the person(s) serving you
- Privacy
- Confidentiality of your records
- Receive accurate information about your health-related concerns
- Know the effectiveness, possible side effects and problems of all forms of treatments
- Participate in choosing a form of treatment
- Receive education and counseling
- Consent to, or refuse any care or treatment
- Review your medical record with your clinician
- Amend your medical records
- Receive any information about services
I ALSO HAVE THE RESPONSIBILITY TO:
- Seek medical attention promptly
- Be honest about your medical history
- Ask about anything you do not understand
- Follow health advice and instructions
- Report any changes in health or medication
- Respect our policies
- Seek care during normal business hours and to provide useful feedback regarding our services and policies
If applicable, at the time of treatment, I can neither be pregnant nor nursing*

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I have provided my past and current medical history and medications*

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I consent to the taking of photographs during the course of my laser therapy for healthcare records – we must be able to document any reactions, pre-existing marks in the area, etc. These will be unidentifiable and will remain with your medical records*

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I consent to using my photographs for medical education and/or marketing purposes

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ACKNOWLEDGMENT: I understand the information given to me and the risks that have been outlined. I will be given the opportunity to ask questions about the procedure during my consultation and will not proceed with treatment until my questions regarding the procedure and the risks associated have been answered satisfactorily. I am fully aware that my condition is of cosmetic concern and that the decision to proceed is based solely on my expressed desire to do so with a complete understanding of the risks. *

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Client Signature
If minor, Parent/Legal Guardian Signature

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Simply Skin Las Vegas

Simply Skin Las Vegas