Lumenis Treatment Consent Form

Patient Name:

Please read each statement below, and complete each section accordingly.

Please select the doctor performing your IPL treatment:

Please check each box:

I understand that there is a rare possibility of side effects or serious complications including permanent discoloration and scarring. I am aware that careful adherence to all advised instructions will help reduce this possibility

I understand that sun exposure or tanning of any sort is not aligned with the pre and/or post-care instructions and may increase the chance for complications

The procedure as well as potential benefits and risks have been thoroughly explained to me and I have had all my related questions answered

Pre and post-care instructions have been discussed and are completely clear to me

I understand that results may vary with each individual and acknowledge that it is impossible to predict how I will respond to the treatment and how many sessions will be required

I consent to photographs being taken for the purpose of documenting my progress and response to the treatment and be kept solely in my medical record

I agree to review the following IPL™/laser pre-treatment compliance checklist along with my Physician and bring accurate and updated data, to the best of my knowledge

I understand the below list of short-term effects and agree to follow matching guidelines:

Flaking of pigmented lesions – crusts may take 5 to 10 days to disappear and it is important not to manipulate or pick which may otherwise lead to scarring
Discomfort – during the procedure, I might experience a sensation similar to a rubber band snap which will vary per my skin condition and area sensitivity but that does not last long. A mild “sun-burn” sensation may follow for typically up to one hour and will be reduced with application of cooling and soothing creams
Reddening and swelling – severity and duration depend on the intensity of the treatment and the sensitivity of the area to be treated. These phenomena may be reduced with application of cooling and/or inflammatory creams
Bruising may rarely occur and may last up to 2 weeks

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List all current medications:

Write N/A if not currently taking any.

My signature certifies that I have duly read and understood the content of this informed consent form, and gave the accurate information as to my health condition. I hereby freely consent to M22™ skin treatments. You will sign this form in office and it will be uploaded to your documents for HIPPA purpose.

Your information will be encrypted.