Celebrity Cosmetic Dermatologist

Consent Form for Diode Mixed Alexandrite Laser Treatment for Hair Loss

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 informed about the Diode Mixed Alexandrite Laser treatment for hair loss, including its purpose, benefits, risks, side effects, and post-treatment care. I voluntarily consent to proceed with the procedure.

2. Description of the Procedure

The Diode Mixed Alexandrite Laser is a non-invasive laser therapy designed to stimulate hair follicles and improve hair density by increasing blood circulation and promoting cellular regeneration in the scalp. This treatment may be used as part of a comprehensive plan to manage hair thinning or hair loss due to conditions such as androgenetic alopecia or telogen effluvium.

How it Works:

• The laser emits specific wavelengths of light that penetrate the scalp, targeting dormant or weak hair follicles.

• The procedure is non-invasive, typically lasting 20–30 minutes per session, and may require multiple treatments for optimal results.

3. Expected Benefits

The treatment aims to:

1. Stimulate hair growth and improve hair density.

2. Strengthen existing hair follicles and reduce further hair loss.

3. Enhance the overall health of the scalp.

I understand that results vary based on individual response, the extent of hair loss, and adherence to a personalized treatment plan. Multiple sessions may be required for noticeable improvements.

4.Common Side Effects (Temporary and Mild)

These side effects are typical and usually resolve within hours to a few days:

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

2. Warmth or Tingling: Sensation of heat or tingling during and immediately after the treatment.

3. Swelling (Edema): Temporary swelling, especially in sensitive areas of the scalp.

4. Dryness or Flakiness: Temporary dryness or peeling of the scalp as the skin regenerates.

5. Itching: Mild itching due to increased blood flow or healing processes in the scalp.

2. Less Common Side Effects

These side effects occur less frequently but may require additional care:

1. Hyperpigmentation: Darkening of the skin in the treated area, more likely in individuals with darker skin tones.

2. Hypopigmentation: Lightening of the skin, which may be temporary or permanent.

3. Increased Shedding: Temporary shedding of weaker hair as the laser stimulates dormant hair follicles (part of the natural hair cycle).

4. Minor Bruising: Bruises caused by heat or pressure from the laser.

5. Sensitivity: Scalp sensitivity, which may cause discomfort with hair products or treatments for a short period.

3. Rare but Serious Side Effects

These complications are uncommon and may require medical attention:

1. Burns or Blisters: Rare burns due to improper laser settings or increased scalp sensitivity.

2. Scarring: Permanent scars in the treated area, especially if the skin's healing process is disrupted.

3. Infections: Bacterial or fungal infections if the scalp barrier is compromised.

4. Excessive Swelling or Redness: Persistent inflammation that does not resolve within the normal recovery period.

4. Long-Term Risks

Rarely, long-term complications may occur, including:

1. Changes in Skin Texture: Uneven skin texture or thickened areas in the treated region.

2. Prolonged Pigmentation Issues: Persistent hyperpigmentation or hypopigmentation in some patients.

3. Scalp Sensitivity: Long-term sensitivity to sun exposure or hair products.

5. Psychological and Emotional Effects

Some individuals may experience:

1. Disappointment: If results take longer than expected or are not immediately noticeable.

2. Anxiety: About temporary hair shedding or skin reactions during the recovery phase.

Key Notes for Patients

• Most side effects are mild and temporary, resolving within a few days to weeks.

• Serious complications are rare and often linked to non-compliance with post-treatment care or pre-existing scalp conditions.

• Proper adherence to pre- and post-treatment instructions can significantly reduce risks.

5. Contraindications

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

• Active scalp infections or skin conditions (e.g., psoriasis, eczema).

• Recent sunburn, tanning, or use of tanning products on the scalp.

• Pregnancy or breastfeeding.

• History of keloid or hypertrophic scarring.

• Current use of photosensitizing medications or conditions causing photosensitivity.

• Medical conditions affecting hair loss that require alternative treatments (e.g., alopecia areata)

6. Pre-Treatment and Post-Treatment Instructions

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

Pre-Treatment:

1. Avoid direct sun exposure or tanning for at least 2 weeks before treatment.

2. Wash and dry the scalp prior to each session.

3. Discontinue the use of harsh scalp treatments (e.g., exfoliants or retinoids) 5 days prior.

Post-Treatment:

1. Apply a recommended moisturizer or soothing product to the treated area if needed.

2. Use sunscreen on the scalp if exposed to the sun (SPF 30 or higher).

3. Avoid using heat-styling tools, harsh hair products, or hair dye for 48 hours after treatment.

4. Refrain from strenuous activities, saunas, or hot showers for 24 hours.

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.