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*(NOTE: THIS PATIENT INFORMED CONSENT TEMPLATE IS PROVIDED “AS IS” AND IS INTENDED FOR INFORMATIONAL PURPOSES ONLY. THIS TEMPLATE MAY NOT MEET ALL STATE AND FEDERAL LEGAL OR REGULATORY REQUIREMENTS FOR USE WITH PATIENTS. PHYSICIANS USING THIS TEMPLATE ARE RESPONSIBLE FOR ENSURING THE INFORMED CONSENT FORM USED WITH PATIENTS MEETS ALL APPLICABLE STATE AND FEDERAL LEGAL AND REGULATORY REQUIREMENTS, AND ARE ENCOURAGED TO CONSULT WITH THEIR ATTORNEY.)

I hereby authorize ___Sarah O’Donnell_____ to perform laser C02 treatment on me. I understand that this procedure works to ablate the tissue on the treatment area. I understand that I may require several treatments to obtain a significant, long-term results. I understand I may experience redness, dryness, sloughing of the tissue, mild to moderate sunburn sensation and/or bleeding post treatment. I understand all the potential side effects, as discussed with me prior to treatment. I understand that genetics, hormones, medication and skin color may interfere with the ability to perform an effective treatment.

The procedure may result in the following adverse experiences or risks: DISCOMFORT/PAIN – Some discomfort and/or pain may be experienced during treatment, but is unlikely. REDNESS/SWELLING/BRUISING – Redness (erythema) or swelling (edema) of the treated area is common and may occur. There also may be some bruising. HYPOPIGMENTATION / HYPERPIGMENTATION: (Changes in skin Color): – During the healing process, there is a slight possibility that the treated area may become either lighter (hypopigmentation) or darker (hyperpigmentation) in color compared to the surrounding skin. This is usually temporary, but, on a rare occasion, it may be permanent. WOUNDS – Treatment can result in burning, blistering, or bleeding of the treated area(s), but is unlikely. SUN EXPOSURE / TANNING BEDS / ARTIFICIAL TANNING - May increase risk of side effects and adverse events. If any of these occur, please call our office. INFECTION – Infection is a possibility whenever the skin surface is disrupted, although proper wound care should prevent this. If signs of infection develop, such as pain, heat, or surrounding redness, please call our office __3252771132_____. SCARRING – Scarring is a rare occurrence, but it is a possibility if the skin surface is disrupted. To minimize the chances of scarring, it is IMPORTANT that you follow all post-treatment instructions provided by your healthcare staff. EYE EXPOSURE – Protective eyewear (shields) will be provided to you during the treatment. Failure to wear eye shields during the entire treatment may cause severe and permanent eye damage.

I acknowledge the following points have been discussed with me: Potential benefits of the proposed procedure, including the possibility that the procedure may not work for me Alternative treatments and my options Reasonably anticipated health consequences if the procedure is not performed Possible complications/risks involved with the proposed procedure and subsequent healing period.

For women of childbearing age: By signing below I confirm that I am not pregnant and do not intend to become pregnant anytime during the course of treatment.

Photographic documentation will be taken. I hereby do___do not___authorize the use of my photographs for teaching purposes.

ACKNOWLEDGMENT

BY MY SIGNATURE BELOW, I ACKNOWLEDGE THAT I HAVE READ AND FULLY UNDERSTAND THE CONTENTS OF THIS INFORMED CONSENT FOR LIGHT BASED HAIR REMOVAL TREATMENT, AND THAT I HAVE HAD ALL MY QUESTIONS ANSWERED TO MY SATISFACTION BY MY HEALTHCARE TEAM.

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