This informed-consent document has been prepared to help inform you about your laser treatment procedure, its risks, contraindications and adverse effects. It is important that you read this information carefully and completely.

I am aware of the following possible occurrences/risks:

• DISCOMFORT – A slight warming sensation or MILD to MODERATE PAIN may be experienced during treatment.
• REDNESS/SWELLING/BRUISING – Short-term redness (erythema) or swelling (edema) of the treated area is common and may occur. There also may be some bruising.
• SKIN COLOR CHANGES – During the healing process, there is a 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 rare occasions, it may be permanent.
• ITCHING/DRY SKIN – Treatment may result in itching and/or dry skin.
• RED RASH/BUMPS – Red rash/bumps may appear after the treatment. This resolves with time.
• WOUNDS – Treatment can result in burning, blistering, or bleeding of the treated areas. 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.
• 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.
• SUN EXPOSURE / TANNING BEDS / ARTIFICIAL TANNING - May increase the risk of side effects and adverse events.
• 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.
• OTHER – Tissue necrosis, hemosiderin staining, paresthesia and ulcerations may also occur.

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.
• The possibility of developing an allergic reaction necessitating medical help.
• Contraindications for the laser procedure (see back side).

I hereby declare that

• I do not meet any contraindication for this laser procedure.
• I agree to the possible occurrence of side effects.
• I agree to have the laser procedure done.
• I will immediately find professional help in case of an allergic reaction.

I give consent for the photographs taken during the treatment to be used in medical and promotional materials and publications, providing that my identity remains hidden, and that I cannot be recognized from the photographs.

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 the treatment.

General laser contra-indications

1. Absolute (Er:YAG and Nd:YAG)

• History of a histologically demonstrated malignant disease in the area to be treated
• Clinical findings indicative of malignant disease
• Hyperthyrosis if the neck region is to be treated
• Epilepsy
• Pregnancy
• Active systemic infection
• Previous treatment with ionizing radiation in the area to be treated.

2. Relative (Er:YAG and Nd:YAG)

• History of a histologically demonstrated malignant disease
• History of wound healing disorders, including but not limited to post-inflammatory hyperpigmentation, abnormal scarring and keloid scarring
• Infection of the treatment area, including but not limited to viral, bacterial or fungal infections of tissues
• Inflammation of the treatment area, including but not limited to infection or autoimmune diseases
• Fever
• Systemic or local autoimmune disorders
• Neurological disorders
• Laser treatment of the testicular area
• History of photosensitivity disorder
• Use of medications, which promote photosensitivity in the last 6 months, including but not limited to tetracyclines, fluoroquinolones, thiazide diuretics, phenothiazine, sulfonamides and vitamin A derivatives
• Type 1 diabetes
• Type 2 diabetes
• Use of anti-platelet medications, including but not limited to COX inhibitors, ADP inhibitors or thromboxane inhibitors
• Use of anticoagulation medications, including but not limited to coumarins, heparins or factor Xa inhibitors
• Use of vasodilators
• Conditions or diseases that limit blood coagulation
• Conditions or diseases that limit platelet function
• Conditions or diseases that limit blood oxygen capacity, including but not limited to heavy blood loss
• Connective tissue disorders
• Gold therapy.

3. Additional relative contra-indications in Aesthetics and Dermatology (Er:YAG and Nd:YAG):

• Recent excessive sun exposure, tanned skin
• Any tissue in the proximity of or on top of any kind of implants.

All of the information is true and accurate to the best of my knowledge.