Selecting "Yes" indicates you have read, understood, and accepted the terms of the Informed Consent below. I, [NAME] have given Harlem Zen permission to perform Nd: YAG and/or Diode laser procedures on my person. The LightPod Neo® (Nd: YAG 1064nm) laser is FDA approved for a variety of procedures including hair removal, vein treatment, and wrinkle reduction. The 3-in-1 Diode laser is FDA approved for full body hair removal. This form provides the information you need to make an informed choice of whether or not to undergo laser treatment. Although laser treatment is effective in most cases, no guarantee can be made that a specific patient will benefit from treatment. The laser emits an intense beam of light that is absorbed in specific body tissues within the skin and depending upon the type of procedure, several treatments may be required at intervals specified by the physician. Some of the possible complications of laser treatment are: 1. Discomfort – The procedure is done so precisely that surrounding tissue is minimally affected; the patient may experience a mild sensation of pain in the treated areas. Some degree of skin flushing may occur, but it typically resolves within several hours. 2. Scarring – There is a small chance of scarring, including hypertrophic scars, or very rarely, keloid scars. To minimize the chances of scarring, it is important that you follow all postoperative instructions carefully. It is important that any prior history of unfavorable healing be reported. 3. Pigmented changes – The treated area may heal with lighter or darker pigmentation. This occurs more often in darker pigmented skin and following exposure of the area to the sun. It is recommended that you protect yourself from any sun exposure for at least three months following treatment. Hyperpigmentation usually fades in three to six months. However, pigment change can be permanent. 4. HSV Reactivation – The patient agrees to notify the physician if he/she has any history of Herpes viral infections, as the laser procedure may cause it to reactivate. 5. Lack of Treatment Response – There is a possibility that the targeted hairs, veins, or other treated areas will not respond to the treatment. This is often a function of the specific body chemistry of the patient, including relative pigmentation and light absorption characteristics of the patient’s various body tissues. 6. Photography - I agree to have photos taken of the area with the exception of genital areas to track the progress of the treatments. Photographs may be used for promotional purposes. 7. Eye Exposure – There is also the risk of harmful eye exposure to laser surgery. Safeguards should be provided by the laser practitioner. It is important that you keep your eyes closed and have protective eyewear at all times during the laser treatment. I certify that I have read or have had read to me, the content of this form. I understand the risks and alternatives involved in this procedure. I have had the opportunity to ask questions and all of my questions have been answered. I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive here are voluntary and I release this institution and/or skincare professional from liability and assume full responsibility thereof.
