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152 West Tiverton Way Suite 160 Lexington KY 40503 Patient Consent for IPL/Photofacial
This consent is designed to give ______________________________ the information needed to make an informed decision to undergo IPL/Photofacial treatment. Photofacial is not an experimental treatment and is considered to be a cosmetic procedure that is not covered by insurances. IPL/Photofacial is a series of at least 5 treatments at 3-4 week intervals. The wavelength, exposure, duration and energy level are chosen to selectively damage targeted skin problems without damaging the surrounding tissue. The intense pulsed light energy is absorbed by damaged tissue. IPL/Photofacial intends to treat benign skin conditions to lighten, fade unwanted blood vessels, freckles, fine lines, scars, stretch marks, uneven skin coloring, tone and texture. Individual results from these treatments vary. Contraindications include pregnancy, accutane, epilepsy or those who have a history of seizures, diabetes (we do not treat below elbows or knees), chemo or radiation therapy, pacemaker, internal defibrillator, any internal metal device (surgical screws, pins, plates or implants) in the area to be treated, HIV positive (a letter of clearance is needed), multiple sclerosis (a letter of clearance with confirmation that the treated area to be treated is not numb), scleroderma, lupus, sarcoidosis, children under the age of 12, treatment over numbness of any body part, over moles or lesions of any kind, over tattoos, port wine stains, under the eyebrows, or any orifice. Use of photosensitizing medications may cause increased skin sensitivity to IPL/ Photofacial treatments. Sun exposure: No direct sun tanning or tanning bed or booth usage or artificial tanning product usage while undergoing IPL/Photofacial treatments. If you will be in the sun you must protect your skin with sunblock applied every 2 hours and a hat or light clothing (whichever appropriate) for protection is necessary. Possible side effects include scarring, discoloration or lightening of skin and hair loss in the area of treatment. Short term side effects following IPL/Photofacial are reddening, mild tingling, bruising, blistering or swelling. If any of these should occur you must contact our office immediately so that we can evaluate and document the occurrence. History of cold sores requires a prescription for Valtrex, which needs to be started the day of or 1 day prior to IPL/Photofacial treatment and followed for 4 more days taking two pills a day. Eye exposure: While there is minimal risk of inadvertent harmful eye exposure to laser, safeguards have been provided including the use of protective eyewear during treatment. It is important that you keep the protective goggles/eye shields on at all times during treatment. For IPL/Photofacial to be optimally successful, I accept responsibility in complying with the post treatment skin care instructions and products advised by this office. I agree to have photographs taken of me to document the progress of my treatments. I consent to the use of these photographs for quality control and educational purposes. I fully understand the risks associated with IPL/Photofacial and agree to have IPL/Photofacial performed on me. ________________________________
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Carolina Skin Care, P.A. (In relation to your visit today) Allergies: Any non medication allergies, history of hives, itching, etc. □No □Yes explain ___________________________________________________________________ __________________________________________________________________________________ Cardiovascular: Any problems with your heart such as palpitations, murmurs,

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