INFORMED CONSENT FOR LASER THERAPY - LIABILITY WAIVER AND RELEASE

I understand that a LASER is being used for my treatment. Although laser therapy is safe and effective in the
majority of cases, unexpected adverse events may occur. Unexpected side effects may result from the use of the
laser & the expected response of the treated area may not be achieved.

• Short term effects: I understand that there are multiple short term effects that may occur, including reddening,
irritated raised rash, mild burning, swelling, bruising, numbing, temporary pigmentary change, blistering,
scabbing, crusting, flaking & sensitivity to the sun. Although these effects typically resolve within several days,
they may persist for several weeks and rarely, even longer. I understand that the degree of the side effects varies
from person to person, and it may not be possible to predict how I will respond.

• Possible permanent effects: I understand that although most side effects are short term and resolve fairly
quickly, some effects may be permanent. Scarring, changes in pigmentation & hair loss may be permanent.

• Discomfort associated with procedure: I understand that the laser functions by heating up its target (blood
vessels, pigmentation). This heating sensation is minimized by the use of the cooling piece, but some level of
discomfort may be felt. The level of discomfort depends on the treatment being done, and varies from person to
person. The stinging or sensation of heat is typically short but may persist for several hours after the procedure.

• Effects of UV: I understand that sun exposure, tanning beds, sunless tanning lotions, and tanning creams can
cause discoloration or reaction to laser treatment during and after the procedure. Having any kind of tan prior to
therapy or soon after therapy results in an increased chance of blistering, permanent or temporary discoloration,
scarring, and discomfort. I understand that avoidance of any UV exposure 1 month prior and 2 weeks after
treatment reduces the risk of these effects.

• People excluded from therapy: I understand that certain patients should not have laser treatment. This includes
any patients who have open wounds, malignant skin tumors, patients who have certain disease that make them
sensitive to light, patients currently on Accutane (Isotretinoin) or who have been on Accutane within in the last 3
months, and in many cases, patients who have tattoos.

• Need for multiple treatments: I understand that some conditions being treated by the laser may require multiple
treatments to obtain the desired results. Everyone responds in different ways and different rates to the treatment.

• Tattoo/permanent makeup: If there are any tattoos or permanent makeup in the area, there is a possibility of
blistering and lightening of the tattoo/makeup.

• Photographs: I understand photos or video of my treatment may be taken. These may be used for teaching health
professionals or shown for scientific reasons. I will NOT be identified in any photo or video.

• For laser vein treatment: I understand that this procedure involves a laser to coagulate the vessels and a bruising
effect could last up to 6 months. It is possible the results will be minimal or not help at all. I realize that each
individual’s treatment response is different; therefore it could require multiple treatments to achieve desired
results. Other options are available, and may include sclerotherapy, surgery or no treatment.

• I agree to wear proper eyewear. Eye injury due to use of the laser is a risk to the patient and to the clinician;
however, the risks are almost completely eliminated with the use of proper eyewear.