DRY EYE TREATMENT

We are 100% committed to the health and well-being for everyone. We are doing everything we can to keep potential exposure out of our office.

As part of the local and state guidelines you must answer no to all the following questions each time you enter Pua Manu MedSpa.

Not present a fever over 100 F/ 37 C.
Not presenting cold, cough, difficulty breathing muscle pain, headache,
loss of taste/smell or pink eye in past 5 days.
Not in contact with anyone with these symptoms in the past 5 days.
Not in contact with anyone diagnosed with COVID-19, sick and quarantined, in the past 5 days.
All information above is true. I may be asked again when I arrive for my appointment.
ALL PATIENTS AND STAFF ARE REQUIRED TO:

Stay home if you are sick or are exhibiting symptoms of illness such as a fever or persistent cough.
Face mask are required to enter the Spa.
Refrain from shaking hands or other touching rituals.
Wash hands for 60 seconds with soap and warm water prior to treatment or use hand sanitizer.
Refrain from eating or drinking while in the Spa, face mask should not be removed.
I understand that Pua Manu MedSpa has put in place reasonable safety measures to help reduce the spread of COVID-19.

I understand that I am consenting to an elective treatment/procedure that is not urgent or emergent. I understand that it may put me at increased risk for becoming infected with COVID-19, due to potential community exposure.

Patient acceptance*

What is Dry Eye Syndrome? Dry Eye is a medical condition that affects millions of people in the United States. It affects tear production. There is either insufficient tear production or poor quality tears. The tear layer is composed mainly of 3 components: protein, 90% water and oil to cover and protect all layers from evaporation.

Symptoms of Dry Eyes. Symptoms of Dry Eyes include stinging, burning, itching, redness, irritation or discomfort. It may lead to blurry vision when working on the computer or reading and it may cause contact lens intolerance. Consequences of not treating Dry Eyes correctly may lead to chronic inflammation that may further decrease tear production creating a vicious cycle.

Precautions:

Let the Nurse or Dr. know if you have been exposed to too much sun or if you are taking certain medications that leaves them photosensitive such as: Tetracycline, Doxycycline, Sulfamethoxazole, Ciprofloxacin, Levofloxacin, Chloroquine, Plaquenil, Vinblastine, Dacarbazine, Amiodarone, Nifedipine, Quinidine, Diltiazem, Accutane.*

If there is pigmentation on the skin, it may turn darker with treatment or it may flake off with time. *

I understand that my Dry Eye Treatment has been approved by the FDA for the rejuvenation and restoration of a more youthful state of the skin. Nevertheless, I wish to have Dry Eye Treatment performed on my eyelid and I am willing to accept the potential risks that my physician has discussed with me. I acknowledge that there may be other, unknown risks and that the long-term effects and risks of Dry Eye treatment are not known. *

Discounted or special priced treatments must be prepaid in full by first treatment appointment. Incomplete and/or cancelled treatments will be charged at regular/full price, NO refunds. *

Photos are necessary and will be taken before, during and after the course of my treatments for medical purposes and to evaluate treatment effectiveness. I understand that my photos will be kept confidential in my electronic patient record. *

I have read the full consent and Dr. Chen has answered all the questions that I may have. I fully consent Dr. Chen or a licensed service provider to proceed with the Pulsed Light laser treatment for my dry eyes.

Patient Signature*

Name*

First NameLast Name

Date*

Date

Providers Signature