Informed Consent Cynosure Elite

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Informed Consent Cynosure Elite Powered By Docstoc
					                                                                               16605 Southwest Freeway, Suite 400
                                                                                      Sugar Land, TX 77479
                                                                                         (281) 275-0800
                                                                                       (281-275-0801 (fax)
                                                                                   www.methodistFMG.com


                                                Laser Hair Reduction Informed Consent
    Initials
                 The purpose of this treatment is to reduce or eliminate unwanted hair. I understand that the results from this
                 treatment vary with each individual. The Cynosure Elite laser produces an intense burst of light that is absorbed
                 by the hair follicle without causing damage to the surrounding tissue.

                 All personnel in the treatment room, including myself, will wear protective eyewear to prevent damage from
                 this intense light.

                 The sensation of the light is uncomfortable and may feel like a pinprick or burst of heat that lasts a few seconds.
                 All the options and possible side effects have been discussed with me. The use of a topical anesthesia is at the
                 discretion of the technician.

                 The laser/light energy is absorbed by the pigmented hair shaft and is transferred to the surrounding follicle.
                 The heat build-up caused by the absorption of energy by the hair itself damages the follicle and retards or
                 prevents future hair production by that follicle.

                 The number of hairs that are permanently removed as a result of one treatment can vary. In most instances,
                 multiple treatments are necessary in order to achieve permanent hair reduction. Some patients require
                 occasional ongoing treatment to maintain best results.

                 Blistering, scarring, hypopigmentation (lightening of the skin) and hyperpigmentation (darkening of the skin) are
                 possible risks and complications of this procedure. Sun exposure and not adhering to post care instructions may
                 increase my chance of complications. The area should be treated delicately following treatment.

                 I do / do not consent to having photographs taken during the course of my laser treatment to be retained
                 as part of my file. I understand if I do consent to photographs, they are the property of MFMG and are kept
                 confidential.


                 Acknowledgment: By my signature below, I certify that:

                       I have read and fully understand the content of this permission form for Cynosure Elite laser treatment and
                      that the disclosures referred to herein were made to me.

                      I have received and read the documentation provided describing in full detail the consultation process, the
                      procedure, the risks/discomfort/complications, and benefits of Cynosure Elite laser treatment.

                      I have read and understood all information presented to me before signing this consent.

                      I have had ample opportunity to ask questions regarding laser hair reduction, side effects and after care.

                      I understand it is my responsibility to inform the technician of any medical or prescription changes.



Signed: ______________________________________________                            Date: _______________________________
        Patient or person legally authorized to consent for patient

Witness: ______________________________________________                           Date: _______________________________

				
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posted:7/13/2012
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