Medical Aesthetic Clinic
Beauty 361 Laser Treatment Consent
Client’s Name: _______________________________Date: ________________
I consent to and authorize to have the Beauty 361 Laser Treatment, which combines the use of three laser technologies:
Near Infrared Skin Tightening (NIR); NIR is a non-invasive and no down time laser based technology for tightening loose and sagging skin. NIR tightens the skin using a safe, gentle light that triggers a biological response to accelerate collagen remodeling in the skin’s dermal layers and will smooth out fine lines, wrinkles, and sagging skin. NIR light therapy heats up tissue within the “live layers” of the skin causing collagen fibers to contract and tighten.
Laser Pixel; laser Pixel for fractional ablative skin resurfacing is to reduce or partially eliminate signs of photodamaged/aged skin, skin tags, facial wrinkles or reduce scarring from skin conditions such as acne. The laser Pixel technology targets only small segments of the total skin mosiac, leaving uninjured skin areas to facilitate rapid wound healing. In other words, only a fraction of tha target area – not the entire surface area – is damaged. The pain level is minimal, and under normal conditions, unless requested by the patient, no local anesthetic is usually used. Generally, the results of the laser Pixel for fractional ablative skin resurfacing demonstrate improvement in the smoothness of the skin; however, a complete elimination of wrinkles or scarring is not a realistic expectation.
PhotoFacial/IPL; Light can be used effectively to destroy targets located in the skin with minimum damage to the surrounding tissues. Light is used to lighten, fade or remove photo-damaged skin in a nonablative manner, a procedure known as photo rejuvenation. Visible signs of photo damage include wrinkling, enlarged pores, course skin texture, and pigment alterations.
Possible Effects of Beauty 361 Laser:
Pain- Minimal discomfort, burning sensation or very mild pain and possible mild swelling in the first few hours after the procedure. A local anesthetic is applied prior to the treatment, but some degree of discomfort may appear after the procedure and this pain may persist for several hours-days.
Redness of Skin – Erythema or redness of skin (1st degree burn) of the skin for several hours up to 2 days period.
Wound Healing – Flakiness of the treated area, usually persisting for 2-7 days.
Skin Thickening- Textural changes of the treated skin, such as skin thickening, which may persist for a variable amount of time.
Skin Tightness – Sensation of skin tightness can appear 24 hours post-treatment.
Herpes Simplex Dermatitis (Fever Blisters) – Occurrence or recurrence of herpes simples dermatitis, particularly if not pre-, intra-, and post-operatively treated with a systemic antiviral medication such as Zovirax.
Skin Itchiness – Pruritis or itching in the early healing phase as early as 24 hours post-treatment and may persist for up to 7 days.
Skin Hyperpigmentation – Transient hyperpigmentation (darkening of the skin), especially in darker – skinned people, occurring three to eight weeks after laser therapy and can be permanent.
Scarring – Which can be hypertrophic or keloid, can occur.
There is known and expected loss of hair in the treated areas.
Even though appropriate measuers are taken to reduce side effects, they cannot be completely eliminated in every case. I understand that the treatment may involve risks of complication of injury from both known and unknown causes, and I freely assume these risks. There may be other treatment options, such as injections, other types of lasers/light sources or peels. With this in mind, I am choosing this non-invasive treatment for vascular and/or pigment lesions and other indicated skin conditions.
No Accutane use for 6 months prior to treatment.
Do not tan the areas to be treated for 4 weeks prior to treatment.
Stop all Retin-A, Retinol, Renova, glycolics, bleaching creams and exfoliatants, use for 7 days before the treatment.
All lotions and potions you are using must be discussed and cleared in your consultation prior to treatments. In addition, all medications must be disclosed and discussed.
Pigmented lesions will not be treated.
A topical anesthetic may be used if you are especially sensitive to the treatment.
Treatment area should be free of perfume, make-up, and lotions.
A cold compress (do not use ice) and skin care products (such as Organic Almond Oil, or Organic Aloe) directly recommended by our staff may be useful to reduce swelling or discomfort.
Over-the-counter pain or anti-inflammatory medication may be used. Hydrocortisone (steroid) cream may decrease any itching or skin irritation. Discuss any reactions with staff members.
Avoid sun exposure and tanning creams during the entire course of treatments. Use SPF 30 or greater on the treatment area at all times.
Do not scrub or exfoliate the treatment area. Do not use any products on the treated area without first consulting our staff.
No hot tubs, whirlpools or baths for the first 48 hours, but showers are okay.
Avoid excessive sweating for 24 to 48 hours. No saunas or vigorous working out.
Follow up consultation is included in the Beauty 361 Laser Treatment for 1 week after the initial treatment.
Repeated treatments will produce the best results.
If the client has any questions or concerns, please call the office at 408-356-7050.
I understand that unprotected sun bathing must be avoided for a period of 3 months. To do so would encourage skin pigment changes and rhytids (wrinkles) necessitating further treatment.
I also understand that more than one Beauty 361 Laser procedure may be required to achieve the optimal obtainable results.
I understand the practice of medicine and surgery is not an exact science and I acknowledge that no guarentees have been made to me concerning the results and procedure. It is not possible to state every complication that may occur as a result of Beauty 361 Laser procedure.
I authorize the taking of photographs.
My physician has explained the Beauty 361 Laser Procedure and its risks, benefits and alternatives and has answered all my questions about the Beauty 361 Laser procedure. I therefore consent to having Beauty 361 Laser procedure.
With this form, I give my full consent for all photographs/footage captured, during and after my treatment by Beauty Redefined to remain the property of the clinic.
Patient Signature: __________________________________________ Date: _______________
Witness Signature: __________________________________________ Date: _______________
I refuse to have my photograph taken, being fully aware that this will eliminate the opportunity to evaluate the effectiveness of my procedure.
Signature: _____________________________ Date: ________________
A Medical Aesthetic Clinic
Beauty 361 Post Treatment Instructions
DAYS 1-2 You will be experiencing redness in areas where the Pixel Laser was used. Your skin will sting similar to a harsh windburn. Your color may appear blotchy as some areas may have been treated more aggressively than others and could even be puffy or swollen. Do not moisturize, we want the skin to peel and rejuvenate naturally.
Immediately after treatment, we will apply a wound-healing product such as Aloe and sunblock.
Wash with cool water only as needed to remove make-up, etc. When cleansing, use a gentle cleanser such as Vivite Replenish Hydrating Cleanser (nothing with glycolic acid) , rinse and pat dry with a soft towel.
Immediately after cleansing, apply a wound healing product such as Vivite Replenish Hydrating Cream and a sunblock (if going outside at all). Periodically throughout the day re-apply sun protection if outside (every 1-2 hours).
Stinging or burning may occur immediately after applying any of the above cleanser and topicals but should stop within 5-10 minutes. The pixel has removed the natural barrier on your skin; therefor some irritation is expected (and not harmful) as well as just simply touching the treated area with your hands to apply topicals will induce irritation.
Organic aloe may be gently sprayed, cold compress or cold packs can be applied to the treated area throughout the day to control discomfort and swelling.
Avoid direct sun exposure and harsh chemicals that may cause stinging (peroxide/hair color, alcohol, raw onions, raw peppers, anything with glycolic acid). If you come into contact with chemicals, wash hands, then rinse the treated area with cool water for relief and re-apply wound healing product.
Do not rub skin, use a wash cloth, sponge, etc.
Sleep with elevated head to minimize swelling.
DAYS 3-4 or once the sensitivity has subsided and skin is flaky
The redness and blotchy appearance of the most severely treated areas will start subsiding. Your skin may appear more taut and shiny than usual. Although your skin looks fine, it is important to remember that you are still healing and must follow the treatment regimen. Your skin will feel “crusty”, flaky, and dry as the healing progresses.
Wash morning and night with cool water, a gentle cleanser such as the Vivite Replenish Hydrating Cleanser, rinse and pat dry with a soft towel.
Immediately after cleansing, apply a wound healing product such as Vivite Replenish Hydrating Cream and a sunblock (if going outside). Periodically throughout the day re-apply sunblock (every 1-2 hours if outside).
Avoid direct sun exposure.
Do not pick or peel flaky skin. Use a wash cloth, sponge, etc.
You may begin using Vivite products with glycolic acid or bleaching cream one week after procedure. You may also use a light exfoliator, such as Vivite Exfoliating Cleanser, to remove any remaining “flaky” skin or schedule a professional diamond microdermabrasion for smoother, longer lasting results.
Once skin is done flaking, you may return to your normal daily skin care regimen.
Avoid direct sun exposure during treatment series as you may be more prone to a sunburn or hypopigmentation.
If you have any questions or concerns call us immediately 408-356-7050
Receive 25% off any SkinMedica products purchased at the time of your Beauty 361 Laser Appointment.
Signature: ___________________________________Date: _____________________
Witness: ___________________________________ Date: _____________________