PLEASE READ THE INFORMATION BELOW BEFORE YOUR Q10 TREATMENT
THEN COMPLETE THE FORM
Various medications and medical conditions will prevent you from having Q-10 Laser treatment. Please ensure you agree to the following statements to the best of your knowledge.
I have not changed medications in the last 2 weeks
I have not been using Isotretinoin ( Roaccutane) in the last 6 months
I have not had a surgical operation in the last 6 weeks.
I have not been exposed to sunshine or an electric sun bed in the last two weeks to the areas I will be treating.
I am not sunburned or my skin is red, sore or peeling in the area to be treated.
I do not currently have fake tan on the areas I will be treating.
I do not have active skin disease or infection or untreated skin cancer in the treatment area
I do not have compromised immune system, AIDS / HIV or Hepatitis
I am not pregnant / breastfeeding
I have not had a chemical peel or microdermabrasion, Botox, fillers treatment in the area to be treated in the last 2 weeks.
I do not have Vitiligo.
This document is a written confirmation of my discussion about Q-10 Q-Switched Nd:YAG laser treatment.
I understand the nature of my condition, the nature of the procedure, the alternative treatments available, and the benefits to be expected compared with alternative approaches.
I understand that optimal results are achieved with a series ( if necessary ) of treatments and that I will not see optimal results after one treatment.
The need to complete a treatment plan has been fully explained to me.
I understand that clinical results may vary depending on my response to laser and my compliance with pre- and post-treatment instructions. I have followed all pre-laser requirements previously provided to me and I understand and will follow the recommendations provided here for post treatment care of my skin, which have been discussed with me. Just as there are benefits to the procedure proposed.
I understand that this procedure also involves risks and possible healing “down time”, excluding laser toning / soft peel which is typically a no downtime procedure.
I understand that serious complications are rare but possible. Common side effects after Carbon peel treatments include temporary redness and mild “sunburn” like effects that may last a few hours to a day or more.
Pigment changes (light or dark spots on the skin) or prolonged redness lasting 1-3 months or longer may occur.
Other potential risks include itching, pain, bruising, infection, scarring and swelling.
I understand that laser light can cause eye damage and provided protective eyewear must be worn during treatment.
I consent to photographs being taken and authorize their anonymous use for public or staff education, marketing or for medical record documentation.
The procedure, as well as potential benefits and risks, have all been explained to my satisfaction. I have had all my questions answered to my satisfaction. I freely consent to the proposed treatment.