CLIENT ASSESSMENT

How would you estimate your current health status? *
Do you have or have you engaged in any of the following... *

Informed Consent

I was informed that: - there is no guarantee for success of laser therapy nor for the duration of achieved results - laser interacts with tissue through photothermal effect, producing thermal tissue remodelling - there are possibilities for temporary adverse effects as are: redness, edema, scars, burns and pain during the procedure - at some patients there are possibilities of overreaction due to higher sensiblity which may require immediate medical help (Emergency) I hereby declare that - I’m accepting the risks to the procedure or treatment proposed as well as possible side effects - in the case of overreaction to therapy I shall immediately seek a medical help (emergency). I have read and understand this form and all my questions have been addressed and answered to my satisfaction. I agree to the terms of this agreement. *
Disclaimer: Informed consent documents are used to communicate information about the proposed treatment of a disease or condition along with disclosure of risks and alternative forms of treatment. The informed consent process attempts to define principles of risk disclosure that should generally meet the needs of most patients in most circumstances. However, informed consent documents should not be considered all inclusive in defining other methods of care and risks encountered. Your physician may provide you with additional or different information which is based on all the facts in your particular case and the state of medical knowledge. Informed consent documents are not intended to define or serve as the standard of medical care. Standards of medical care are determined on the basis of all of the facts involved in an individual case and are subject to change as scientific knowledge and technology advance and as practice patterns evolve. It is important that you read the above information carefully and have all of your questions answered before signing the consent. *
1. I recognize that during the course of the procedure and treatment, unforeseen conditions (like fainting) may necessitate different procedures than those above. I therefore authorize the above NP and assistants, or designees to perform such other protocol that are in the exercise of his or her professional judgment necessary and desirable. *
2. I consent to the administration of such anesthetics considered necessary or advisable like topical lidocaine or Pronox (laughing gas). I understand that all forms of anesthesia involve risk and the possibility of complications, injury. and sometimes death. *
3. I acknowledge that no guarantee has been given by anyone as to the results that may be obtained. *
4. If asked, I consent to the photographing of the procedure(s) to be performed, including appropriate portions of my body, for educational purposes, provided my identity is not revealed by the picture. *
5. For purposes of advancing aesthetic medical education, If asked, I consent to the admittance of observers to the treatment room. *

Potential and common side effects that may occur with Picosecond & FOTONA LASER treatments:

• DISCOMFORT may be minimal to moderate. Some areas are more sensitive than others. Topical anesthetic is available for purchase if required. Certain laser treatments include a prescription grade topical anesthetic or can be added on for an additional fee.

• INFLAMMATION which may include irritation, itching, pain, bruising, flaking, ingrown hairs, typically subside/fade in 5-7 days

• ERYTHEMA (redness) and mild to moderate “sunburn” like effects may last for a few hours to 2-5 days

• EDEMA (swelling) of the skin around the treatment site may last 2-5 days, but can be reduced with regular application of a cold gel pack

• PUSTULES or PIMPLES may develop in the first few days following treatment and gradually subside

• TEXTURE CHANGES - Transient texture changes often occur, but usually resolve with time

• BLISTERING, SCABBING or CRUSTING may occur and usually take 4-10 days to heal.

• PETECHIAE may be present after treatment and may last 3 - 5 days. 

• FRECKLES/PIGMENT – Existing freckles/pigment in the treated area may temporarily or permanently disappear

• COINCIDENTAL HAIR REMOVAL – There is a possibility of coincidental hair removal when treating pigmented or vascular lesions in hair-bearing areas

8. IT HAS BEEN EXPLAINED TO ME IN A WAY THAT I UNDERSTAND: a. THE ABOVE TREATMENT OR PROCEDURE TO BE UNDERTAKEN b. THERE MAY BE ALTERNATIVE PROCEDURES OR METHODS OF TREATMENT c. THERE ARE RISKS TO THE PROCEDURE OR TREATMENT PROPOSED I CONSENT TO THE TREATMENT OR PROCEDURE AND THE ABOVE LISTED ITEMS (1-8). I AM SATISFIED WITH THE EXPLANATION. *
I acknowledge that beauty and medi spa treatments, including, but not limited to: Eyelash Exensions, Lash LIfts, skin care, massage, microablation, microdermabrasion, waxing, hair and scalp treatments, nail treatments, electrolysis, facial toning, permanent cosmetics, body treatments, ionization, laser treatments, tattoo removal, vein treatments, brown spot removal, BOTOX, Collagen, Dermal Fillers, PRP Injections, Sclerotherapy, Piercing Mesotherapy, Dermaplaning, and various other beauty procedures is not an exact science and no specific guarantees can or have been made concerning the outcome. I understand that some clients experience more change and improvement than others. In virtually all cases, multiple treatments are required in order to realize a difference. On behalf of myself, my heirs, my executors, and my administrators, I understand and agree to assume the following risks and hazards which may occur in connection with any particular treatment including but not limited to: unsatisfactory results, soreness, poor healing, discomfort, redness, blistering, skin damage, nerve damage, disability, death, scarring, infection, change in skin pigmentation, allergic reaction, eye damage, change or damage to my vision, muscle damage, and increased hair growth. I understand that even though precautions may be taken in my treatment, not all risks can be known in advance. Given the above, I understand that response to treatment varies on an individual basis and that specific results are not guaranteed. Therefore, in consideration for any treatment received, I agree to unconditionally defend, indemnify, hold harmless and release from any and all liability, costs of litigation and any other costs of every kind and nature, the company and the individual that provided my treatment, the insured, their insurance company, and any additional insureds, as well as any officers, directors, or employees of the above companies for any injury, property damage, condition or result, known or unknown, that may arise as a consequence of any treatment that I receive. The release contained herein will be onstrued to apply to the greatest extent permitted by law and, if permitted by law, will apply even if any such injury or damage is caused in whole or in part by the released parties' own negligence or the negligence or willful conduct of any other individual. In the event any provision of this agreement is found to be legally invalid or unenforceable for any reason, all remaining provisions will remain in full force and effect. In the event any provision of this document is found by a court of competent jurisdiction to exceed the limits permitted by any applicable law or to be invalid or unenforceable as written, such court (s) may exercise its discretion in reforming such provision(s) to the extent necessary to make it reasonable and enforceable. I understand and agree that any legal action of any kind related to any treatment I receive will be limited to binding arbitration using a single arbitrator agreed to by both parties. It is understood that any such arbitration will be final and binding and that by agreeing to arbitration, the dersigned is waiving their rights to seek remedies in court, including the right to a jury trial. The undersigned waives, to the fullest extent permitted by law, any right they may have to a trial by jury in any legal proceeding directly or indirectly arising out of or relating to this agreement whether based in contract, tort, statute (including any federal or state statute, law, ordinance, or regulation), or any other legal theory. The insured agrees that this contract will be governed and construed in occordance with the laws of the state of South Dakota and that all actions of any kind whatsoever will be heard, governed, arbitrated, and restricted to the venue of the County of Meade County, South Dakota. The ndersigned also agrees and stipulates that they will be responsible for any legal, or other costs of any kind, incurred by the insured or their insurance company in defense of this agreement should the undersigned challenge its enforceability. The client indicated below also agrees to forever hold harmless and release from any and all liability, claims, or demands of any kind or nature the insured, and their insurance company for the transmission of any disease, condition, injury or illness they may allege to have contracted or been exposed to as the result of any treatment, person, or visit at the insured's location or the location of treatment. I have fully disclosed on my client intake form any medications, previous complications, or current conditions that may affect my treatment. In consideration for treatment received, I hereby grant permission to the individual or company that provided my treatment to use any photographic treatment records for the purposes of clinical and statistical studies, advertising, or promotion without any additional compensation to me. *
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