I {name} hereby authorize the therapist to treat my wart(s) using a laser device.  I understand that multiple treatments may be required and it is possible the result will be minimal or may not help at all.

 The procedure may result in the following adverse experiences or risks:

• DISCOMFORT/PAIN –Discomfort and pain may be experienced during treatment.
• REDNESS/SWELLING/BRUISING – Short term redness (erythema) or swelling (edema) of the treated area is common and may occur. There also may be some bruising.
• SKIN COLOR CHANGES – During the healing process, there is a possibility that the treated area 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.
• WOUNDS – Deep tissue injury and prolonged wound healing may occur.  Treatment can result in burning, blistering, or bleeding of the treated areas. If any of these occur, please call our office.
• INFECTION – Infection is a possibility whenever the skin surface is disrupted, though proper wound care should prevent this. If signs of infection develop, such as pain, heat or surrounding redness, please call our office on 01582 460 868.
• SCARRING – Scarring is a rare occurrence, but it is a possibility if the skin surface is disrupted.  To minimize the chances of scarring, it is IMPORTANT that you follow all post-treatment instructions provided by your healthcare staff.
• SUN EXPOSURE / TANNING BEDS / ARTIFICIAL TANNING - May increase the risk of side effects and adverse events.
• EYE EXPOSURE – Protective eyewear (shields) will be provided to you during the treatment.  Failure to wear eye shields during the entire treatment may cause severe and permanent eye damage.

I acknowledge the following points have been discussed with me:

• Potential benefits of the treatment of warts, including the possibility that the procedure may not work for me.
• Alternative treatments such as topical or oral medications or even surgery
• Reasonably anticipated health consequences if the procedure is not performed
• Possible complications/risks involved with the proposed procedure and subsequent healing period

For women of childbearing age: By signing below I confirm that I am not pregnant and do not intend to become pregnant anytime during the course of treatment. Furthermore, I agree to keep The AL5 Aesthetics informed should I become pregnant during the course of treatment.

ACKNOWLEDGEMENT

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 BY MY HEALTHCARE TEAM.