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 14 days.
• Not in contact with anyone with these symptoms in the past 14 days.
• Not been off island and returned without being quarantined for 14 days.
• Not in contact with anyone diagnosed with COVID-19, sick and quarantined, in the past 14 days.

All information above is true. I may be asked again when I arrive for my appointment. 
ALL PATIENTS AND STAFF ARE REQUIRED TO: 

• Please follow our local and state regulations and guidelines, including those related to occupancy levels, social distancing and other measures intended to reduce the spread of viruses.
• 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 agree to comply to the rules listed above.

 

I also understand that the novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. I further understand that COVID-19 is extremely contagious and is believed to spread by person-to-person contact, and as a result, federal and state health agencies recommend social distancing. I understand that Pua Manu Medspa has put in place reasonable safety measures to help reduce the spread of COVID-19.

I understand that COVID-19 may cause additional risks, some of which may not be known at this time.

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’S ACCEPTANCE OF RISKS

By signing this consent form I accept the risks described above and give my permission to proceed with the treatment/procedure.

I have read this consent or someone has read it to me and want to proceed.

BBL treats a broad range of skin conditions caused by skin aging and sun exposure. In addition, the photothermal energy targets and eliminates many of the fine vessels that cause redness and the unwanted melanin responsible for pigmented lesions.

Phototherapy BBL - BroadBand Light technology utilizes the power of pulsed light to deliver excellent phototherapy results. The light energy delivered by the BBL gently heats the upper layers of the skin. The heat absorbed by the targeted areas stimulates the skin cells to generate new collagen. This process helps restore the skin to its natural stage ☐ Vascular Conditions - Visible vessels, broken capillaries, spider veins, vascular lesion and discoloration of your skin will be gently eliminated from the upper layers of your skin surface.

Wrinkle Reduction - Ablative and non-ablative laser or light wavelengths can create thermal tissue injury which accelerates the wound-healing process. Fibroblasts generate new collagen, plumping the skin and correcting skin imperfections. After a procedure, dermal collagen matrix rejuvenation causes visible wrinkles, scars, tone and texture to soften or be eliminated.

Pigmented Lesions BBL - BroadBand Light technology treats sun-damaged and aging skin effectively. The light energy delivered will gently be absorbed by the unwanted melanin responsible for pigmented lesions in the upper layers of the skin. Over the next few days the pigmented lesions will darken and fall off. This procedure allows for quick recovery with smoother, healthier, more vibrant skin, and an immediate change in skin texture and tightness.

I understand that there is a possibility of rare side effects such as reddening, mild burning, temporary bruising and discoloration, and in rare cases blistering of the skin. These effects have all been fully explained to me. I understand that I may require more than one treatment to correct my skin problem, one treatment may not be sufficient.

 

Up to 5 treatments will be required depending on skin type and depth of the problem. I also understand that there are other options for treatment that are available and each of these other options has been fully explained to me. Before and after treatment instructions have been given to and discussed with me. This procedure as well as alternative treatment, potential benefits and risks have been explained to me. I have had all my questions answered to my satisfaction. I will not hold Dr. Chen or anyone in this practice responsible or liable for any non-compliance on my part or for any damages incurred otherwise.

I understand BBL is purely elective, insurance does not cover this procedure, that I am solely responsible for payment, and that there are no refunds for procedures. Fee structure and payment have been fully explained to me.

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. 

 

I understand that necessary photos 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. 

 

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. 

consent to photographs and other audio-visual and graphic materials before, during and after the course of my treatments to be used for marketing and medical educational purposes. Although the photographs or accompanying material will not contain my name or any other identifying information, I am aware that I may or may not be identified by the photos.

I have read the full consent and Dr. Chen has answered all the questions that I may have and fully consent Dr. Chen or a licensed service provider to proceed with the BBL laser treatment. 

Patient Signature