We are 100% committed to the health and well-being for everyone. We are doing everything we can to keep potential exposure out of our office.

As part of the local and state guidelines you must answer no to all the following questions each time you enter Pua Manu Medspa.

• Not present a fever over 100 F/ 37 C.
• Not presenting cold, cough, difficulty breathing muscle pain, headache,
  loss of taste/smell or pink eye in past 14 days.
• Not in contact with anyone with these symptoms in the past 14 days.
  Not been off island and returned without being quarantined for 14 days.
• Not in contact with anyone diagnosed with COVID-19, sick and quarantined, in the past 14 days.

All information above is true. I may be asked again when I arrive for my appointment. 
ALL PATIENTS AND STAFF ARE REQUIRED TO: 

• Please follow our local and state regulations and guidelines, including those related to occupancy levels, social distancing and other measures intended to reduce the spread of viruses.
• Stay home if you are sick or are exhibiting symptoms of illness such as a fever or persistent cough.
• Face mask are required to enter the Spa.
• Refrain from shaking hands or other touching rituals.
• Wash hands for 60 seconds with soap and warm water prior to treatment or use hand sanitizer.
• Refrain from eating or drinking while in the Spa, face mask should not be removed. 

I agree to comply to the rules listed above.

 

I also understand that the novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. I further understand that COVID-19 is extremely contagious and is believed to spread by person-to-person contact, and as a result, federal and state health agencies recommend social distancing. I understand that Pua Manu Medspa has put in place reasonable safety measures to help reduce the spread of COVID-19.

I understand that COVID-19 may cause additional risks, some of which may not be known at this time.

I understand that I am consenting to an elective treatment/procedure that is not urgent or emergent. I understand that it may put me at increased risk for becoming infected with COVID-19, due to potential community exposure.

PATIENT’S ACCEPTANCE OF RISKS

By signing this consent form I accept the risks described above and give my permission to proceed with the treatment/procedure.

I have read this consent or someone has read it to me and want to proceed.

I authorize Dr. Nancy Chen and/or licensed service provider to perform laser/pulsed light cosmetic skin treatments on me, including, but not limited to, the treatment of pigmented lesions (for example, sun spots, age spots, and other skin discolorations), vascular lesions (for example, red spots, leg veins and small spider veins, but not varicose veins), wrinkles, (rhytides), furrows, fine lines, textural irregularities, non-ablative skin resurfacing, soft tissue coagulation, ablative skin resurfacing, and reducing or eliminating hair. I understand that the procedure is purely elective, that the results may vary with each individual, and multiple treatments may be necessary

 

I understand that:

• The Palomar Icon® Aesthetic System is a pulsed-light and laser system that delivers a precise pulse of light energy that is absorbed by a chromophore in skin, for example, hemoglobin in the blood or pigment in a lesion, causing a thermal reaction. All personnel in the treatment room, including me, must wear protective eyewear to prevent eye damage from this light energy.

• The sensation of light is sometimes uncomfortable and may feel like a moderate to severe pinprick or flash of heat. Anesthesia or sedation (calming medication) may be advisable for laser skin resurfacing treatments. If the practitioner or physician elects to use an anesthetic to reduce discomfort during any light-based treatment, all options and risks associated with the anesthetic will be discussed with me.

• The treated area may be red and swollen for two to twenty-four (2–24) hours or longer. Cooling the area after the treatment (for example, ice packs, topical gels) may help reduce discomfort and swelling.

• Common side effects include temporary redness (erythema) or mild "sunburn"-like effect that may last a few hours to 3-4 days or longer. Other potential side effects include, but are not limited to, crusting, irritation, itching, pain, burns, scabbing, swelling (edema), broken capillaries, bronzing, and acne or herpetic breakouts. There also is a risk of resulting unsatisfactory appearance and failure to achieve the desired result.

• Pigment changes, including hypopigmentation (lightening of the skin) or hyperpigmentation (darkening of the skin), lasting one to six (1-6) months or longer or permanently may occur. Freckles may temporarily or permanently disappear in treated areas.

• Serious complications are rare but possible, such as, scarring, blood clots, skin loss, hematomas (collection of blood under the skin), and allergic reaction to medications or materials used during the procedure.

• I understand and accept that with skin resurfacing treatments, there may be an increased length of social downtime associated with the level of treatment. There also is a chance of additional side effects like blanching and significant redness.

• With ablative laser treatments, there are additional risks of discomfort, focal areas of bleeding, bruising, poor healing, serous discharge, and infections. Serious but rare complications may include scarring, abscess, skin necrosis (dead skin), and injury to other internal structures including nerves, blood vessels, or muscles.

• An occlusive ointment may be used to cover the treated skin and keep it moist to avoid the skin drying out and being crusty or desquamated. Occlusion may exacerbate acne breakouts under the ointment.

• There is no guarantee that the expected or anticipated results will be achieved.

• Sun, tanning bed, or tanning lamp exposure, the use of self-tanning creams, and not adhering to the posttreatment instructions provided to me may increase my chance of complications. I must avoid the sun, tanning beds, and sunless tanning lotions and use sunblock (SPF 45 recommended) after treatment.

• There is a possibility of coincidental hair removal when treating pigmented or vascular lesions in hair-bearing areas. There is a risk that the hair regrowth may be changed, such as little or no regrowth or more regrowth than before.

• I should call my provider as soon as possible if I have any concerns about side effects or complications after treatment.

• I hereby consent to the administration of any anesthesia or sedation considered necessary or advisable for my procedure(s). I understand that all forms of anesthesia and sedation involve risk and the possibility of complications, injury, and in rare instances death.

• Not providing my medical history before proceeding with a light-based treatment could impact treatment results and cause complications

 

Acknowledge

I understand that necessary photos will be taken before, during and after the course of my treatments for medical purposes and to evaluate treatment effectiveness. I understand that my photos will be kept confidential in my electronic patient record.

 

Discounted or special priced treatments must be prepaid in full by first treatment appointment. Incomplete and/or cancelled treatments will be charged at regular/full price, NO refunds

I have read and understand all information presented to me before consenting to treatment. I have had all my questions answered.