Please read each statement. Complete, underline or circle individual selection accordingly.

• I authorize the Klaudia Walec to perform IPL TM treatments on me in an effort to improve Dyschromia / Hyperpigmentation / Hair Reduction / PWS /Haemangioma / Angioma / Rosacea / Telangiectasia /
  Other
• I understand that there is a rare possibility of side effects or serious complications including permanent discoloration and scarring. I am aware that careful adherence to all advised instructions will help reduce this possibility

• I understand the below list of short-term effects and agree to follow matching guidelines:
  • Flaking of pigmented lesions – crusts may take 5 to 10 days to disappear and it is important not to manipulate or pick which may otherwise lead to scarring
  •  Discomfort – during the procedure, I might experience a sensation similar to a rubber band snap which degree will vary per my skin condition and area sensitivity but that does not last long. A mild “sun-burn” sensation may follow for typically up to one hour and will be reduced with application of cooling and soothing creams
  • Reddening and swelling – severity and duration depend on the intensity of the treatment and the sensitivity of the area to be treated. These phenomena may be reduced with application of cooling and/or anti-inflammatory creams
  • Bruising may rarely occur and may last up to 2 weeks

• I understand that sun exposure or tanning of any sort is not aligned with the pre and/or post-care instructions and may increase the chance for complications 
• The procedure as well as potential benefits and risks have been thoroughly explained to me and I have had all my related questions answered 
• Pre and post-care instructions have been discussed and are completely clear to me 
• I understand that results may vary with each individual and acknowledge that it is impossible to predict how I will respond to the treatment and how many sessions will be required 

• I consent to photographs being taken for the purpose of documenting my progress and response to the treatment and be kept solely in my medical record 
• I consent to photographs being used for medical education or publication with applied discretion and not revealing my identity 
• I agree to review the following IPL TM pre-treatment compliance checklist along with my Physician and bring accurate and updated data, to the best of my knowledge