Celebrity Cosmetic Dermatologist

Fractional CO2 Laser Treatment Consent Form

Prime HealthAddress: 1035 Sterling Rd, Suite 104, Herndon, VA 20170Physician Name: Dr. Han Tonthat

1. Purpose of this Consent

By signing this form, I confirm that I have been informed about the Botox procedure, its potential benefits, risks, and side effects. I voluntarily agree to undergo treatment with Botox (Botulinum Toxin Type A) for aesthetic purposes.

2. Description of the Procedure

The Fractional CO2 Laser is a skin resurfacing treatment designed to address skin concerns such as:

• Wrinkles and fine lines.

• Scars (e.g., acne or surgical scars).

• Hyperpigmentation and uneven skin tone.

• Skin texture irregularities.

The laser works by delivering controlled beams of light to create micro-injuries in the skin, stimulating collagen production and natural skin repair. Results vary based on the individual and the condition being treated. Multiple sessions may be necessary for optimal results.

3. Expected Benefits

The goal of the procedure is to:

• Improve skin texture and tone.

• Reduce the appearance of scars, wrinkles, and pigmentation.

• Promote collagen regeneration for a rejuvenated appearance.

4. Potential Risks and Side Effects

I understand that while Fractional CO2 Laser treatment is generally safe, there are potential risks and side effects, including but not limited to:

Common Side Effects:

1. Redness: Mild to moderate redness lasting up to 1–2 weeks.

2. Swelling: Temporary swelling, particularly in sensitive areas like around the eyes.

3. Itching: Mild itching as the skin heals.

4. Peeling and Flaking: Normal as treated skin regenerates.

5. Dryness: Temporary dryness that may require moisturization.

Less Common Side Effects:

1. Prolonged Redness or Swelling: Lasting several weeks in rare cases.

2. Hyperpigmentation: Temporary darkening of the treated area, particularly in individuals with darker skin tones.

3. Hypopigmentation: Loss of pigment in treated areas, which may be permanent.

4. Burns or Blisters: Rare but may occur if the laser penetrates too deeply.

Rare but Serious Risks:

1. Infection: Bacterial, viral, or fungal infections, including reactivation of herpes simplex (cold sores).

2. Scarring: Permanent scarring if healing is impaired.

3. Prolonged Sensitivity: Heightened skin sensitivity lasting weeks to months.

4. Changes in Skin Texture: Irregularities such as uneven skin tone or rough patches.

5. Eye Injury: Damage to the eyes from laser exposure, mitigated by protective eyewear.

5. Contraindications

I confirm that I do not have any of the following conditions that may increase risks:

• Active skin infections, open wounds, or inflammatory skin conditions.

• A history of keloid or hypertrophic scarring.

• Recent use of isotretinoin (e.g., Accutane) within the last 6 months.

• Pregnancy or breastfeeding.

• Conditions affecting the immune system or healing ability.

• A history of photosensitivity or taking medications that increase photosensitivity.

6. Pre-Treatment and Post-Treatment Instructions

To minimize risks and ensure proper healing, I agree to follow the instructions provided by the Clinic:

Pre-Treatment:

1. Avoid direct sun exposure for at least 2 weeks before the procedure.

2. Discontinue use of retinoids, acids, or exfoliants 5–7 days before treatment.

3. Notify the Clinic of any medications, including blood thinners or antibiotics.

Post-Treatment:

1. Apply recommended moisturizers and sunscreen daily.

2. Avoid sun exposure and wear broad-spectrum sunscreen (SPF 30 or higher).

3. Avoid strenuous activities, hot showers, or saunas for 48–72 hours.

4. Refrain from picking, scratching, or rubbing the treated area.

Failure to follow post-treatment instructions may result in complications or suboptimal results.

7. No Guarantee of Results

I understand that aesthetic outcomes are subjective and may vary. While the procedure is performed with care, Prime Health cannot guarantee specific results, and touch-ups may be necessary for optimal results.

8. Refund Policy

The Patient acknowledges and agrees to the following refund terms:

1. Non-Refundable Services: All fees for completed services are non-refundable.

2. Health-Related Refunds: If treatments are stopped due to verified health issues, refunds will be issued only for unused treatments.

3. Payment Obligations: If enrolled in a payment plan, the Patient must complete all payments, even if they discontinue the program.

9. Emergency Contact

9. Acknowledgment and Consent

By signing below, I confirm that:

1. I have read and understood this Consent Form and its contents.

2. I have been informed of the procedure, risks, and benefits, and had all my questions answered.

3. I understand the risks, including rare but serious complications, and agree to proceed with the treatment.

4. I release Prime Health, its staff, and practitioners from liability for any complications, except those caused by gross negligence or malpractice.

Patient Compliance and Limitation of Liability Disclaimer (Commonwealth of Virginia)

I understand and acknowledge that laser treatment is an elective medical or cosmetic procedure, and that individual results may vary due to a variety of factors, including but not limited to my skin type, medical history, treatment area, and adherence to medical instructions. I confirm that I have received detailed pre- and post-treatment care guidelines and understand that it is my responsibility to comply fully with all instructions and attend any recommended follow-up appointments.

I acknowledge that failure to follow these instructions or attend follow-up care may negatively impact treatment results and may increase the risk of side effects or complications. Therefore, I hereby release and hold harmless [Clinic Name], its providers, and employees from any and all liability, claims, or damages resulting from adverse outcomes or complications due to my failure to comply with medical advice.

I further understand that no guarantees, warranties, or assurances have been made regarding the results of this treatment, and I voluntarily assume all associated risks in accordance with the laws of the Commonwealth of Virginia.