I hereby authorize Beauty Marx and it's designated provider(s) to remove or lighten the appearance of vascular and/or pigmented lesions. The procedure involves using the laser device to coagulate the vessels and/or treat pigmented lesions, age spots, and sun spots by melanin absorption. I understand it may take several treatments to obtain optimal results and maintenance may be required. Although these devices are effective in most cases, I understand that no guarantees can be made. I understand I may not experience complete clearance, and that it may take several treatments. Some conditions may not respond at all and, in rare cases, may become worse.

SIDE EFFECTS/RISKS:

• DISCOMFORT/ PAIN: Some discomfort may be experienced during treatment. Pain may include the feeling of burning, stinging and radiating pain.
• REDNESS and/or SWELLING: Short term redness (erythema) is common and swelling (edema) of the treated area may occur.
• BRUISING: Bruising is a transient phenomenon that usually
  resolves with time.
• SKIN COLOR CHANGES: There is a slight possibility that during the healing process the areas treated may become either lighter (hypopigmentation) or darker (hyperpigmentation) in color compared to the surrounding skin. This is usually temporary, but on a rare occasion, it may be permanent.
• EPIDERMAL CRUSTING: Pigmented lesions may crust as part of the healing process. It is important not to pick or exfoliate the crusts. They will typically slough off 7-14 days post treatment.
• WOUNDS: Treatment can result in blistering, burning or bleeding of the treated areas. If any of these occurs please contact the office.
• BURNS and/or INFECTION: Infection is a rare possibility whenever the skin surface is disrupted. If signs of infection develop, such as pain, heat or surrounding redness please contact the office.
• SCARRING: Scarring is rare but is a possibility. To minimize the chances of scarring it is important that you follow the post treatment instructions provided.
• EYE EXPOSURE: Protective eyewear will be provided to you during treatment. Failure to wear the eyewear may cause severe and permenant eye damage.
  
  

There are several conditions that deem you ineligible for treatment.

I confirm that I have not taken topic or oral Accutane/Isotretinoin in the last 6 months or Retin A for the last 14 days.

I confirm that I do not have an implantable device e.g pacemaker or defribrillator.

I confirm that I do not have an active oral herpes simplex lesion.    

CONSENT FOR TREATMENT

I HEREBY AUTHORIZE Beauty Marx and its designated provider(s) to perform the treatment explained above. I release all medical staff and specific technicians from liability associated with the procedure. I certify that I am a competent adult of at least 18 years of age. I certify that I am not pregnant.

This consent form is freely and voluntarily executed and shall be binding upon my spouse, relatives, legal representatives, heirs, administrators, successors and assigns. I acknowledge that no guarantee has been given by anyone as to the results that may be obtained. Alternative methods and risks involving this treatment have been explained.

BY MY SIGNATURE BELOW, I ACKNOWLEDGE THAT I HAVE READ AND FULLY UNDERSTAND THE CONTENTS OF THIS INFORMED CONSENT FOR TREATMENT OF VASCULAR/PIGMENTED LESIONS AND THAT I HAVE HAD ALL MY QUESTIONS
ANSWERED TO MY SATISFACTION.