Laser treatment

Laser Treatment—Sciton MicroLaserPeel® The procedure to be performed is the Sciton MicroLaserPeel for skin rejuvenation. I understand that the results from the treatment vary with each individual. By signing below, I understand the following and give consent for treatment. The nature and purpose of the treatment have been explained to me and any questions I have regarding the treatment have been answered to my satisfaction. I acknowledge that I have revealed any current or previous condition that may affect the outcome of the treatment (including but not limited to, photosensitive condition, auto-immune deficiency, herpes, pregnancy, hormonal disease allergies, etc.) and that I have revealed any medications that I am currently taking. Additionally, I acknowledge that I have read and understand the following risks. Risks of Erbium:YAG Laser Treatment of Skin:
1. There are both risks and complications associated with all laser treatment procedures of the skin. Risks involve both items that specifically relate to the use of laser energy as a form of surgical therapy and to the specific procedure performed. An individual's choice to undergo a procedure is based on the comparison of risk to potential benefits. Although the majority of patients do not experience these complications, you should discuss each of them with your surgeon to make sure you understand the risks, potential complications and consequences of laser skin treatment. 2. Infection - Although infection following laser skin treatment is unusual, bacterial, fungal, and viral
infections can occur. Herpes simplex virus infections around the mouth or other areas of the face can occur following a laser treatment This applies to both individuals with a past history of Herpes simplex virus infections and individuals with no known history of Herpes simplex virus infections in the mouth area. Specific medications may be prescribed and taken both prior to and following the laser treatment procedure in order to suppress an infection from this virus. Should any type of skin infection occur, additional treatment including antibiotics may be necessary from your private physician. 3. Scarring -Although normal healing after the procedure is expected, abnormal scars may occur both in
the skin and deeper tissues. In rare cases, keloid scars may result. Scars may be unattractive and of different color than the surrounding skin. Additional treatments may be needed to treat scarring. 4. Color Change - Laser treatments may potentially change the natural color of your skin. There is the
possibility of irregular color variations within the skin including areas that are both lighter and darker. A line of demarcation between normal skin and skin treated with lasers can occur. 5. Accutane (Isotretinoln) - Accutane is a prescription medication used to treat certain skin diseases. This
drug may impair the ability of skin to heal following treatments or surgery for a variable amount of time even after the patient has ceased taking it. Individuals who have taken the drug are advised to allow their skin adequate time to recover from Accutane before undergoing laser skin treatment procedures. You Only Younger 7002 Riverbrook Drive #700 Sugar Land, TX 77479 281-937-7537 6. Patient Failure to Follow Through - Patient follow through following a laser skin treatment procedure
is important. Post operative instructions concerning appropriate restriction of activity, use of dressings, and use of sun protection need to be followed in order to avoid potential complications, increased pain, and unsatisfactory result. Your physician may recommend that you utilize a long-term skin care program to enhance healing following a laser skin treatment. 7. Lack of Permanent Results - Laser or other treatments may not completely improve or prevent future
skin disorders, lesions, or wrinkles. No technique can reverse the signs of skin aging. Additional surgical procedures may be necessary to further tighten loose skin. 8. Delayed Healing - It may take longer than anticipated for healing to occur after laser treatments. Skin
healing may result in thin, easily injured skin. This is different from the normal redness in skin after a laser treatment. I understand I have the right to refuse treatment and due to the nature of this treatment, exact results cannot be predicted. I further acknowledge that no guarantees have been made to me as to the results that may be obtained or the permanence of the treatment. The nature and purpose of the treatment have been explained to me. I have read and understand this agreement. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement. Alternative methods of treatment and their risks and benefits have been explained to me and I understand that I I understand there is no guarantee of results of any treatment. I understand regular charges applies to all subsequent treatments. I understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment. I understand there are no refunds on any services rendered. I further agree in the event of non- payment, to bear the cost of collection, and/or Court cost and reasonable legal fees, should this be required. I release You Only Younger, LLC, medical staff and technicians from liability associated with the procedure. I certify that I am a competent adult of at least 18 years of age. This consent form is freely and voluntarily executed and shall be binding upon my spouse, relatives, legal representatives, heirs, administrators, successors and assigns. Note: All prices are subject to change without prior notice. I consent to photographs being taken to evaluate treatment effectiveness, for medical education, training, professional publications, or sales purposes. No photographs revealing my identity will be used without my written consent. Client’s Name (Please Print):______________________________________________ Client’s Signature_______________________________________________________ You Only Younger 7002 Riverbrook Drive #700 Sugar Land, TX 77479 281-937-7537

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