Celebrity Cosmetic Dermatologist

Pico Laser Treatment Consent Form

Prime HealthAddress: 1035 Sterling Rd, Suite 104, Herndon, VA 20170

Physician Name: Dr. Han Tonthat

1. Purpose of this Consent

By signing this form, I confirm that I have been fully informed about the Pico Laser treatment, including its purpose, potential benefits, risks, side effects, and required post-treatment care. I voluntarily consent to undergo the procedure.

2. Description of the Procedure

Pico Laser is a non-invasive treatment using ultra-short laser pulses to address a variety of skin concerns, such as:

• Pigmentation (e.g., freckles, age spots, melasma).

• Acne scars and other scars.

• Fine lines and wrinkles.

• Uneven skin tone or texture.

• Tattoo removal.

The laser delivers targeted energy to break down pigment and stimulate collagen production, promoting skin rejuvenation. Treatment may involve multiple sessions to achieve desired results.

3. Expected Benefits

The treatment aims to:

1. Improve skin tone and texture.

2. Minimize the appearance of pigmentation and scarring.

3. Promote collagen regeneration for a more youthful complexion.

I understand that results vary based on the individual, the condition being treated, and adherence to post-treatment care instructions.

4.Common Side Effects (Temporary and Mild)

These side effects are normal and usually subside within a few hours to a week:

1. Redness (Erythema): Mild to moderate redness at the treatment area, similar to sunburn.

2. Swelling (Edema): Temporary swelling, particularly around sensitive areas such as the eyes.

3. Dryness: The skin may feel tight or dry post-treatment.

4. Peeling or Flaking: The treated skin may exfoliate as part of the natural healing process.

5. Mild Discomfort: Tingling, stinging, or a slight burning sensation during or immediately after treatment.

6. Temporary Darkening of Pigment (Micropigmentation): Known as "micro-crusting," where pigmentation appears darker before it flakes off.

Less Common Side Effects

These are less frequent but may require attention:

1. Bruising: Minor bruising in areas with sensitive skin or thin blood vessels.

2. Hyperpigmentation: Temporary darkening of treated areas, more common in individuals with darker skin tones.

3. Hypopigmentation: Lightening of skin in the treated area, which may be temporary or permanent.

4. Textural Changes: The skin may feel rough or uneven temporarily as it heals.

5. Prolonged Redness or Swelling: Lasting beyond the typical recovery time of a few days to weeks.

Rare but Serious Side Effects

These complications are uncommon but require medical intervention:

1. Infection:

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

   • Signs include excessive redness, heat, or oozing at the treatment site.

2. Scarring: Permanent scars may form if the skin does not heal properly or if post-treatment care is not followed.

3. Blisters or Burns: Occurs if the laser penetrates too deeply or if the skin reacts adversely to heat.

4. Changes in Sensation:

   • Numbness, tingling, or altered sensation, which may persist for several weeks.

5. Allergic Reaction:

   • Rare sensitivity to the treatment causing redness, itching, or rash.

Long-Term Risks

Rarely, Pico Laser treatments may result in long-term complications:

1. Chronic Pigmentation Issues:

   • Persistent hyperpigmentation or hypopigmentation.

2. Skin Texture Changes:

   • Irregular texture, thickened skin, or thinning in the treated area.

3. Incomplete Pigment Clearance:

   • Residual pigmentation or partial improvement for conditions like melasma or tattoos.

4. Delayed Healing:

   • Prolonged recovery time due to individual skin sensitivity or external factors (e.g., sun exposure).

Specific Risks for Tattoo Removal

1. Residual Tattoo Pigment:

   • Some colors, like green, blue, or white, may not respond fully to the treatment.

2. Ink Darkening:

   • Certain tattoo pigments, such as iron-based inks, may oxidize and temporarily darken before breaking down.

3. Scarring in Dense Tattoo Areas:

   • Risk increases if the tattoo is deep or layered.

Psychological and Emotional Effects

1. Disappointment:

   • Patients may have unrealistic expectations and feel dissatisfied with gradual or partial results.

2. Anxiety About Healing:

   • Temporary anxiety about how their skin looks during the recovery phase.

Important Notes for Patients

• Side effects vary depending on individual skin type, area treated, and adherence to pre- and post-treatment care.

• To minimize risks, patients should follow all pre-treatment and post-treatment instructions provided by the clinic.

5. Contraindications

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

• Active skin infections, rashes, or open wounds.

• A history of keloid or hypertrophic scarring.

• Recent tanning or use of tanning products.

• Pregnancy or breastfeeding.

• Use of isotretinoin (e.g., Accutane) within the past 6 months.

• Photosensitivity disorders or medications causing sensitivity to light.

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 sun exposure and tanning for at least 2 weeks before the procedure.

2. Discontinue use of retinoids, exfoliants, or other active skincare products 3–5 days prior.

3. Notify the Clinic of any changes in medical history or medications.

Post-Treatment:

1. Apply recommended moisturizer and sunscreen daily (SPF 30 or higher).

2. Avoid sun exposure and wear protective clothing.

3. Refrain from using makeup or harsh skincare products for 24–48 hours post-treatment.

4. Avoid hot showers, saunas, and vigorous exercise for 48 hours.

5. Do not pick or scratch the treated area to avoid scarring or infection.

Failure to follow post-treatment care 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.