I understand that the Harmony is a device used for skin rejuvenation and that clinical results may vary in different skin types. I understand there is a possibility of short-term effects such as reddening, blistering, scabbing, temporary bruising and temporary discoloration of the skin, as well as rare side effects such as scarring and permanent discoloration. These effects have been fully explained to me.
Clinical results may vary depending on individual factors, including medical history, skin type, patient compliance with pre/post treatment instructions, and individual response to treatment. I understand that treatment with the Harmony Dye-VL system involves a series of treatments and has been fully explained to me.
I voluntarily consent and authorize that this laser/light assisted treatment be performed and recognize that this treatment is not an exact science and I acknowledge that no guarantees have been made to me as to the result. There are some risks related to the performance of this procedure. I understand and acknowledge that the risks that may occur in connection with this particular procedure may include the following:
Recurrence of the lesions, I may not experience permanent results even with multiple treatments. Pigment changes (skin color). During the healing process, the treated area may become either lighter or darker in color than the surrounding skin. This is usually temporary, but on a rare occasion, it may be permanent. Poor healing may require more than the usual one to three weeks to heal. Once the surface has healed, it may be pink and sensitive to the sun. SPF should be applied to treated areas at all times. Some discomfort may be experienced during and after the laser treatment. I give my permission for the administration of topical anesthesia when and if deemed appropriate.
I certify that I have been fully informed of the nature and purpose of the procedure, expected outcomes and possible complications, and I understand that no guarantee can be given as to the final result obtained. I am fully aware that my condition is of cosmetic concern and that the decision to proceed is based solely on my expressed desire to do so. I confirm that I am not pregnant or nursing at this time, and that I have not taken Accutane within the last 6 months.
I certify that I have been given the opportunity to ask questions and that I have read and fully understand the contents of this consent for.