Download Photo Rejuvination - IPL Consent

PHOTO REJEVENATION- I.P.L.
Patient Name ___________________________________________________ DOB ___________________
If you have black, brown, blue, purple or red on your skin, then you need a photofacial. You will need 1-3 the
first year, then one every year as needed. We can’t guarantee 100% clearance of the skin, results vary from
person to person. Photofacial treatment is used to remove benign vascular and pigmented lesions, as well as
improve the overall appearance of the skin. The light wavelength, exposure duration, and energy level are
specifically chosen for your skin type to selectively damage targeted blood vessels and irregular
pigmentations with minimum damage to surrounding tissues. Clinical results will vary from patient to
patient. We have found that those patients who tend to sunburn rather than tan usually obtain good results
on the first and subsequent treatments. On the other hand, those who tan more easily tend to have more
variation in their results. Some patients in this category will experience partial results and some will
experience no improvement at all. I understand that results are not guaranteed and are dependent upon my
following this schedule. I understand that there is a possibility of rare side effects such as scarring and skin
discoloration. Short term side effects include, but are not limited to: Redness, Mild burning,
Irritation/discomfort, Temporary discoloration of the skin, Pigmentation changes, Temporary swelling,
crusting, bruising, peeling, or flaking, Increased sensitivity to the sun.
BEFORE: We will cleanse your face and use a topical numbing cream to numb the area being treated. We will
also chill the area being treated with ice cold air during the treatment for maximum comfort.
DURING: The area(s) are all treated "like mowing the lawn", we target every single area without missing a
spot. We include a complimentary chemical peel to go along with the photofacial, we think of it as "the icing
on the cake".
AFTER: You may feel like you have a sunburn for no more than an hour and a half after photofacial+chemical
peel.
DAY 1-2: You may apply sunblock and makeup as needed. You might look and/or feel like you have been at
the beach.
DAY 3-5: The damage will exfoliate away. You may apply eye makeup and lipstick during the exfoliting
process. Make sure to keep skin moisturized, "the more moisturized you keep your skin, the less obvious it
will appear that your skin is exfoliating". Two times a day you may massage the skin with an "acid free"
inexpensive moisturizer for about 5 minutes, then wipe away with a warm wash cloth. Once done, reapply
moisturizer. The more damage your skin had prior to the photofacial, the more downtime you will have but
also, the more of a "wow factor" result you will get.
DAY 7-10: Remaining exfoliation could continue, keep skin moisturized. In certain rare cases redness and
irritation can go beyond 10 days.
*ALL BODY PARTS TAKE DOUBLE THE HEALING TIME*
*NO BLEACHING PRODUCTS (RETIN-A/RENOVA, ACCUTANE, GLYCOLIC ACID, ETC)
*NO PRODUCTS THAT CONTAIN ACID.
*NO SUNBATHING, TANNING OR SUN EXPOSURE 10 DAY BEFORE AND 10 DAYS AFTER TREATMENT.
*NO SUN SENSITIVE MEDICATIONS 7-10 DAYS PRIOR TO TREATMENT.
I UNDERSTAND THE IMPORTANCE OF PROPERLY FULFILLING THE APPROPRIATE BEFORE & AFTER
CARE INSTRUCTIONS.
I consent to be photographed before, during and after treatment. These photographs shall be the property of
Facial Techniques. These photographs may be shown for scientific reasons, and/or used in patient education
(both in and out of the office). I understand that I release Facial Techniques, the Medical Supervisor, the
technician performing services and any Facial Techniques employee involved in my treatment from any
liability associated with complications from the Photo Rejuvenation procedure.
SIGNATURE ________________________________________________________
DATE ____________________
WITNESS ___________________________________________________________
DATE ____________________
FACIAL TECHNIQUES. 8140 WALNUT HILL LN. STE 601. DALLAS TX 75231. 214-346-5438