Consent Form

Acne Treatment

Note
This patient informed consent template is provided “as is” and is intended for informational purposes only. This template may not meet all state and federal legal or regulatory requirements for use with patients. Physicians using this template are responsible for ensuring that the informed consent form used with patients meets all applicable state and federal legal and regulatory requirements and are encouraged to consult with their attorney.

PROCEDURE EXPERIENCES OR RISKS

The procedure may result in the following adverse experiences or risks:

Discomfort
Mild to moderate discomfort is typical during treatment.

Erythema and Edema
Mild to significant erythema (redness) and mild to moderate edema (swelling) are common during or developing within several minutes of treatment. Erythema typically resolves within 20 min to several hours, and edema typically resolves within several hours to a day; however, both can last for several days. Application of cold packs immediately after treatment may reduce the severity and duration of both. Swelling and/or redness that develops a few days after treatment, especially if accompanied by warmth, should be evaluated by the treating physician.

Transient Acne Flareups
Mild flareups of inflammatory acne lesions are common after treatment. Flareups have been reported by up to 44% and 50% of subjects enrolled in clinical studies conducted with the AviClear Laser System with moderate and severe inflammatory acne vulgaris prior to treatment, respectively. If acne flareups occur, they typically last a few weeks; however, acne flareups can continue at perceptible levels for several more months.

Blisters
Mild to moderate blisters developing during or within several hours of treatment are uncommon but have been reported. If blisters do develop, care should be taken not to disturb or unroof the blisters to prevent oozing and possible infection. Oozing from blisters that are disturbed or unroofed lasting more than a day should be evaluated by the treating physician.

Crusting/Scabbing
Mild crusting or scabbing is rare but has been reported as typically following blistering. If crusting/scabbing occurs, the crusts/scabs should be allowed to natural slough, without picking, to minimize the likelihood of skin pigmentation changes.

Hyperpigmentation
Brown darkening of the skin (hyperpigmentation) can occur either following blistering or crusting, or as a result of inflammation during the recovery period. If it occurs, it may last for one to several months before normal pigmentation levels return. Hyperpigmentation is very rarely permanent. Your treating physician may recommend topical skin-lightening products to accelerate the return to normal pigmentation levels.

Skin Texture Changes
Transient texture changes are rare and usually resolve with time.

Infection
Despite good wound care, pain, swelling, oozing, and fever can indicate the development of an infection. Topical and/or oral antibiotics may be necessary.

Scarring
Scarring is a rare occurrence, but it is a possibility whenever the skin’s surface is disrupted. To minimize the chances of scarring, it is important that patients follow all posttreatment instructions provided by their healthcare provider. Good post-treatment care will help reduce the possibility of scarring.

Hypopigmentation
Lightening or loss of skin pigment (hypopigmentation) is very rare. Transient hypopigmentation lasting several weeks has been reported following crusting/ scabbing. Permanent hypopigmentation has not been reported; however, it is a possible adverse event, especially in patients with a history of vitiligo or pigmentary disorders.

Altered Hair Growth
The use of lasers that heat the pilosebaceous unit may affect both the sebaceous gland and structures of the hair follicle. Therefore, it is possible that treated areas may exhibit altered hair growth in the future. 

I declare and acknowledge
The following points have been discussed with me:

  • This treatment is not meant to prophylactically treat acne.
  • A flare-up can occur in clear skin.
  • Potential benefits of the treatment of acne, including the possibility that the procedure may not work for me.
  • Alternative treatments, such as topical or oral medications or even surgery.
  • Reasonably anticipated health consequences if the procedure is not performed.
  • Possible complications/risks involved with the proposed procedure and subsequent healing period.

Hydrafacial.

Volume loss, enlarged pores, sun damage, and a general loss of elasticity can all affect your skin’s appearance. Very few treatments can address them all without the need for downtime. Until now. HydraFacial MD® is a gentle, non-invasive treatment consisting of multiple steps, combining cleansing, exfoliating, and hydration to reverse the visible effects of skin aging. It is also capable of producing a deep rejuvenating effect.

The treatment includes hydradermabrasion, a chemical peel, pain-free extraction, and deep hydration. During treatment, the skin receives peptides and antioxidants, which produce a natural glow and ongoing skin benefits.

Who is it suitable for?

The HYDRAFACIAL is suitable for all skin types and tones. It can be performed not only on the face but on the hands, back, buttocks or arms to assist with skin concerns all over the body. This treatment covers a wide range of concerns including:

  • Decongesting skin from impurities (pimples, blackheads, whiteheads & more)
  • Reducing appearance of fine lines and wrinkles
  • Reducing pigmentation
  • Protecting and hydrating the skin with antioxidants
  • Evening out uneven skin textures
  • Reduce the appearance of scarring
  • Assisting with tightening the skin

Cost

SDL HYDRAFACIAL | $250

HYDRAFACIAL FIRE & ICE EXPERIENCE | $450

HYDRAFACIAL BPEEL | $350

Duration

45 – 60 Minutes

Downtime

One of the main advantages of a HYDRAFCIAL in achieving your skincare goals is that it allows you to have beautifully nourished skin without any downtime. This is irrespective of where the HYDRAFCIAL is performed. No down time, instantly smooth and glowy skin.

What is involved?

The HYDRAFACIAL procedure is a three-step process. The first step involves a deep pore cleanse and exfoliation. The second step includes the extraction of impurities using a vortex-fusion tip. In the third step, the skin is infused with antioxidants and hyaluronic acid, with nutrients absorbing into the skin resulting in a fresher look.

Purpose/Goal

Treatment reduces fine lines and wrinkles, increases firmness, evens tone, texture, and brown spots, as well as reducing enlarged pores. Its many benefits include a more hydrated, bright, plump, and clear complexion. Plus, it can also improve signs of aging.

Skin Conditions it targets

  • Wrinkles and fine lines
  • Uneven skin tone
  • Hyperpigmentation
  • Enlarged Pores
  • Loose Skin
  • Dry Skin

How many sessions?

On repeat. The HYDRAFACIAL can be completed regularly every 3-6 weeks.

After Care

Use recommended skin care to uphold your result. Your dermal specialist will base this on your skin diagnostic results and skin goals.