Medical Aesthetic Clinic
Skin Tightening Laser Consent Form
Client’s Name: _____________________________________ Date: ________________
I consent to and authorize to have the Near Infrared (NIR) or Radio Frequency (RF) Laser procedure to be performed on me. NIR/RF LASER is a non-invasive and no down time laser based technology. NIR/RF LASER 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/RF LASER therapy heats up tissue within the “live layers” of the skin causing collagen fibers to contract and tighten.
NIR/RF LASER is the ideal solution for clients who desire a more youthful, healthy, and natural appearance with a non-invasive approach. No surgery, scars, burning or recovery time. Loose skin on the face, arms, legs, back, abdomen, and bottom are ideal areas for the NIR/RF LASER procedure to tighten. Clinical results confirm improvement in more than 90% of clients who have been treated using NIR/RF LASER.
The following problems may occur with the procedure.
1. There is a risk of scarring.
Short term effects may include reddening, mild burning, temporary bruising or blistering. Hyper-pigmentation (browning) and Hypo-pigmentation (lightening) have also been noted after treatment. These conditions usually resolve within 3-6 months, but permanent color change is a rare risk. Avoiding sun exposure before and after the treatment reduces the risk of color change.
Infection: Although infection following treatment is unusual, bacterial, fungal and viral infections can occur. Should any type of skin infection occur, additional treatments or medical antibiotics may be necessary.
Bleeding: Pinpoint bleeding is rare but can occur following treatment procedures. Should bleeding occur, additional treatment may be necessary.
Compliance with the aftercare guidelines is crucial for healing, prevention of scarring, and hyper-pigmentation
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 treatments should be scheduled every 2-3 weeks.
Consistent and repeated treatments will produce the best results
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.
If the client has any questions or concerns, please call the office at 408-356-7050.
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: ________________