1. I hereby request and authorize Dr.
_, M.D., to treat me for the purpose of attempting to improve my appearance.
2. The effect and nature of the treatment to be given, as well as possible alternative methods of treatment, have been fully explained to me.
3. It has been explained that well-qualified and trained personnel will assist with certain portions of the treatment under his/her supervision.
4. I hereby authorize Dr._,M.D., to administer such treatment to me, and agree to hold him/her free and harmless for any claims or suits for damages or injury or complications whatsoever resulting from conditions beyond the doctor's control.
5. I know that the practice of medicine and surgery is not an exact science and that, therefore, reputable practitioners cannot properly guarantee results.
6. I acknowledge that no guarantee or assurance has been made to me by anyone regarding the treatment which I have herein requested and authorized.
7. I am advised that though good results are expected, they cannot be and are not guaranteed, nor can there be any guarantee against untoward results.
8. I acknowledge that no guarantee has been given me as to the number of years I may appear younger following treatment or that the scars will heal completely.
9. I acknowledge that no guarantee has been given me as to the condition of the complexion or size of the skin pores following treatment.
10. I acknowledge that during the procedure my face will be covered by masks for 1 to 2 hours.
11. I acknowledge that no guarantee has been given me as to the painlessness of the procedure. Some individuals, because of emotional makeup or low pain thresh old, may experience discomfort. This procedure will cause a modification in the treated area of my face (body), which may be unpleasant. My face will become red and subsequently dry and hyperpigment-ed. Exfoliation will then start and last about 5-10 days.An erythema may persist for 15-20 days.
12. I have been advised that the following conditions may arise after treatment. These conditions are uncommon and usually not serious, but may appear at any time because of circumstances beyond the doctor's control:
a. A darkening of the skin or blotchiness may occur at any time up to 3 months following treatment. This is usually due to excess sun or heat exposure. Special medication may be prescribed for this and will usually clear the condition completely. Occasionally, further treatment may be required, consisting of a second procedure. Persons with dark complexions undergoing treatment are advised that a blotchy complexion may arise, which will usually even out over a period of 3-6 months.
b. The skin may be red for a 6- to 8-week period or possibly redness is due to increased blood supply to the new skin. This usually disappears over a 3- to 6-month period and the final complexion is somewhat lighter than the original complexion.
c. On occasion, small areas of the neck and chin may show thickening for a variable period of time following treatment. These areas are buildups of underlying collagen and scar tissue and are usually easily controlled by periodic injections of medication.
d. Every facial procedure is accompanied by swelling of the tissue of the face and neck.This is usually only temporary and disappears within a short period of time. On occasion the swelling may be persistent and will require further medication.
13. I have been advised that exposure to sun must be avoided at all costs for a period of 6 months. No sunbathing is permitted for 6 months. To do so would encourage blotchy skin pigmentation requiring further treatment.
14. I give my permission that my before and after pictures will be used for:
- Educational purposes only
- Patient demonstration
- Medical congresses and medical articles
The operation has been explained to me and I fully understand the nature of the procedure and the risks involved. I acknowledge and understand that no expressed or implied warranty has been given to me.
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