I authorize and consent to the treatment of Hair reduction/modification with the Spectrum 810nm Diode laser System manufactured by Rohrer Aesthetics, Inc. I have been advised by the technician of Noble Cosmetic Surgery of the purported advantages and disadvantages associated with this treatment.

I understand that treatment with this laser system varies from patient to patient and that more than 1-treatment may be required.

Although rare, adverse outcomes such as hyperpigmentation and/or hypopigmentation (darkening or lightening of the skin), skin texture changes, and trace scarring can occur. No guarantees have been made to me regarding the outcome of the treatment or any improvements in my condition due to the procedure.

I understand that the possible benefits are the reduction and possibly the elimination of unwanted body hair. Due to the brilliance of the laser light energy used, I agree to wear eye protection to shield my eyes.

I have been given the opportunity to ask questions and have received satisfactory answers to those questions.

I hereby authorize the taking of photographs.

I hereby indemnify and hold harmless Noble Cosmetic Surgery and their employees, the treating technician, and the staff from any and all liability, damages, cost, and expenses arising from or out of the use of the Spectrum 810nm Diode laser for treatment of hair reduction/modification. With all of the above information understood, I am choosing to be treated with the Spectrum 810nm Diode laser System.

I, authorize and consent to the treatment with the Spectrum Laser System manufactured by Rohrer Aesthetics, Inc. I have been advised by, Noble Cosmetic Surgery of the purported advantages and disadvantages associated with this treatment.

I understand that treatment with this laser system varies from patient to patient and that more than 1-treatment may be required.

Although rare, adverse outcomes such as hyperpigmentation and/or hypopigmentation (darkening or lightening of the skin), skin texture changes, and trace scarring can occur.

No guarantees have been made to me regarding the outcome of the treatment or any improvements in my condition due to the procedure.

I understand that the possible benefits are the reduction and possibly the elimination of unwanted pigmented lesions and/or the removal of ink used for tattoos.

Due to the brilliance of the laser light energy used, I agree to wear eye protection to shield my eyes. I have been given the opportunity to ask questions and have received satisfactory answers to those questions.

I hereby authorize the taking of photographs. These photographs will be shared with Noble Cosmetic Surgery. and Noble Cosmetic Surgery may use them in marketing brochures.

I hereby indemnify and hold harmless Noble Cosmetic Surgery and all individuals associated with Noble Cosmetic Surgery, the physician and/or the treating technician, and all staff members at the office of Noble Cosmetic Surgery from any and all liability, damages, cost and expenses arising from or out of the use of the Spectrum Laser System.

With all of the above information understood, I am choosing to be treated with the Spectrum Laser System.

I, authorize and consent to the treatment for the removal of superficial wrinkles and/or pigmented lesions with the Spectrum Laser System. I have been advised by, the Technician of Noble Cosmetic Surgery of the purported advantages and disadvantages associated with this treatment.

I understand that treatment with this laser system varies from patient to patient and that more than 1-treatment may be required. Although rare, adverse outcomes such as hyperpigmentation and/or hypopigmentation (darkening or lightening of the skin), skin texture changes, and trace scarring could occur. No guarantees have been made to me regarding the outcome of the treatment or any improvements in my condition due to the procedure. I understand that the possible benefits are the reduction and the elimination of wrinkles and pigmented lesions. Due to the brilliance of the laser light energy used, I agree to wear eye protection to shield my eyes. I have been given the opportunity to ask questions and have received satisfactory answers to the questions. I hereby authorize the taking of photographs. These photographs may be used to demonstrate the results this laser produces. I hereby indemnify and hold harmless Noble Cosmetic Surgery and their employees, the treating technician from any and all liability, damages, cost and expenses arising from or out of the use of the Spectrum laser for treatment of wrinkles and/or the removal of pigmented lesions. With all of the above information understood, I am choosing to be treated with the Spectrum Erbium Laser System.

Contraindications of Erbium Yag Laser:

Potential Risks of Erbium Yag Laser:

 

1. Several treatments (3-5) are recommended every four weeks.

2. The patient may see lightening of defined pigmented areas.

3. Skin improvements are subtle and will begin to be evident after a series of treatments.

4. Some erythema may last from a few hours to a few days.

5. Hyperpigmentation may occur if the patient does not avoid sun exposure. The patient must use sun block of at least SPF45 on a daily basis and not receive direct sun or artificial sunlight for at least 6 weeks post-treatment.

6. Age spots, and dark spots may also appear, but it is normal.

I authorize and consent to the treatment for the removal of superficial wrinkles and/or pigmented lesions with the Phoenix-15 CO2 Laser.

I have been advised by the technician of Noble Cosmetic Surgery of the purported advantages and disadvantages associated with this treatment.

I understand that treatment with this laser system varies from patient to patient and that more than 1 treatment may be required. Although rare, adverse outcomes such as hyperpigmentation and/or hypopigmentation (darkening or lightening of the skin), skin texture changes, and scarring can occur. No guarantees have been made to me regarding the outcome of the treatment or any improvements in my condition due to the procedure.

I understand that the possible benefits are the reduction and elimination of wrinkles and pigmented lesions.

Due to the brilliance of the laser light energy used, I agree to wear eye protection to shield my eyes.

I have been given the opportunity to ask questions and have received satisfactory answers to those questions.

I hereby authorize the taking of photographs. These photographs may be used to demonstrate the results this laser produces.

I hereby indemnify and hold harmless, Noble Cosmetic Surgery, the treating technician, from any and all liability, damages, cost and expenses arising from or out of the use Phoenix-15 CO2 Laser for treatment of wrinkles and/or the removal of pigmented lesions. With all of the above information understood, I am choosing to be treated with the Phoenix-15 CO2 Laser.

These are potential risks of C02, please sign if you understand and have read the potential risks below.

• Milia, which are small white bumps or cysts, may appear in the laser-treated areas during healing.
  
  
• Acne flares may occur after laser resurfacing. This may resolve on its own or can be treated with conventional acne therapies.
  
  
• Hyperpigmentation, and more rarely, hypopigmentation, may result in the laser-treated areas. In general, the hyperpigmented areas may be treated with bleaching cream to ease fading of the pigment. Hypopigmentation is more difficult to treat.
  
  
• Reactivation of a herpes simplex cold sore may occur, especially after laser resurfacing around the mouth. This can be prevented by giving an antiviral medicine prior to the surgery and continuing it for 7 to 10 days post-procedure.
  
  
• Bacterial infections can be prevented by taking an antibiotic prior to the surgery and continuing for 7 to 10 days post-procedure.
  
  
• Postoperative swelling is to be expected and is lessened by the administration of intramuscular steroids. Patients are encouraged to sleep on an extra pillow at night to help reduce the swelling. Ice pack application is also helpful in the first 24 to 48 hours.
  
  
• Scarring, although rare, may occur in laser-treated areas.
  
  
• Quitting smoking is highly recommended because of its documented harmful effects on the healing process.

The Spectrum Intense Pulsed Light (IPL) is a device used for many aesthetic procedures. Depending on which treatment head is connected, it can be us for the reduction of hyper-pigmentation (brown/red discoloration), unwanted body hair, active acne, and vascular lesions.

I understand that the treatment may involve a series of treatments. Individual response will vary according to skin type, hair color, degree of tanning, follow-up care, and the body area being treated. I understand that there is a possibility of rare side effects that consist of pain, reddening, burning, swelling, fragile skin, discoloration, and temporary bruising of the skin. A crust or blistering may form, which may take 5 to 14 days to heal. Color changes, such as hyper-pigmentation (brown/red discoloration) or hypo-pigmentation (skin lightening), may occur following treatment.

The discoloration may take several months to resolve but in rare cases it can be permanent. Unprotected sun exposure in the weeks before and following treatments is contraindicated as it may cause or worsen this condition. A blue-purple bruise (purpura) may appear on the treated area. This can last a couple of weeks up to a several months to completely resolve. Scarring and burns can occur but is uncommon.

These effects have all been fully explained to me.

I have read and understand this agreement, and all my questions have been addressed and answered to my satisfaction. I understand the procedure, and risks, accept the risks, and request that this procedure be performed on me by a qualified provider. I understand this treatment is entirely voluntary on my part. I hereby indemnify and hold harmless Noble Cosmetic Surgery and all individuals associated with Noble Cosmetic Surgery, the physician and/or the treating technician, and all staff members from any and all liability, damages, cost, and expenses arising from or out of the use of the Spectrum IPL/Laser System.

I, authorize and consent to the treatment for skin tightening with the PiXeI8 - Radio Frequency Micro Needling System.

1. I have been advised by, the treating Technician, of the purported advantages and disadvantages associated with this treatment.
   
   
2. I understand that treatment with this system varies from patient to patient and that more than 1 treatment may be required.
   
   
3. Although rare, adverse outcomes such as skin texture changes and scarring can occur.
   
   
4. No guarantees have been made to me regarding the outcome of the treatment or any improvements in my skin condition due to the procedure. 
   
   
5. I understand that the possible benefits are the tightening of loose skin.
   
   
6. I certify that I do not have any metal implants in the area being treated.
   
   
7. I certify that I do not have any electronic implants (pacemaker, insulin pump, etc.).
   
   
8. I have been given the opportunity to ask questions and have received satisfactory answers to those questions.
   
   
9. I hereby authorize the taking of photographs. These photographs may be used to demonstrate the results this device produces. 
   
   
10. I hereby indemnify and hold harmless Noble Cosmetic Surgery and their employees, the treating technician from any and all liability, damages, cost, and expenses arising from or out of the use PiXel8- Radio Frequency Micro Needling System for treatment of skin tightening.
    
    With all of the above information understood, I am choosing to be treated with the PiXel8-Radio Frequency Micro Needling System.

I consent to the treatment and the above listed items (1-10). I am satisfied with the explanation.

With all of the above information understood, I am choosing to be treated with the PiXel8-Radio Frequency Micro Needling System.

With any treatment, there are certain risks, which must be undertaken. The following are some of the possible complications that may result from this type of treatment, which may be beyond the Doctors or technician's control. Please read, and sign below. Your technician will review this form with you again, the day of your appointment and your questions will be answered.

1. Acne or herpes flare up.
   
   
2. Itching or burning sensation.
   
   
3. Infection.
   
   
4. Skin texture irregularity (normally caused by improper treatment technique or poor application pressure or removing of handpiece before the needles have been fully retracted) White bumps may occur. These bumps should resolve within 1 to 3 months without further intervention.
   
   
5. Transient hair growth.
   
   
6. Darkening or lightening (hyperpigmentation and hypopigmentation) of the skin around the treatment area. Most skin pigmentation changes are transient and should resolve on their own within a few months. However, in rare cases, the skin pigmentation change may be permanent 
   
   
7. Burn or blister (scarring is rare).
   
   
8. Pigmented rash on the skin (redness)
   
   
9. Contact dermatitis
   
   
10. Scarring
    
    
11. Possible Bruising may occur.
    
    
12. Inflammation or swelling.
    
    
13. Brown crusting, will shed and reveal younger healthy-looking skin.

It is difficult to predict how long the results of this procedure will last. The results may vary due to individual differences. No guarantees can be made to the exact time of recovery or the ultimate shape of those areas in which Microneedling is performed.

I have read and clearly understand the above risks and consent to treatment with this knowledge.

I, authorize and consent to the treatment for vaginal health with the Phoenix CO2 Laser

I have been advised by, Nurse Practioner/Technician of Noble Cosmetic Surgery of the purported advantages and disadvantages associated with this treatment. I understand that treatment with this laser system varies from patient to patient and that more than 1 treatment may be required. No guarantees have been made to me regarding the outcome of the treatment or any improvements in my condition due to the procedure. I understand that the possible benefits are the reduction of pain during intercourse, reduction of itchiness in the vaginal area and increased lubrication in the vaginal area (vaginal health). Due to the brilliance of the laser light energy used, I agree to wear eye protection to shield my eyes. I have been given the opportunity to ask questions and have received satisfactory answers to these questions. I hereby authorize the taking of photographs. These photographs may be used to demonstrate the results this laser produces. I hereby indemnify and hold harmless Noble Cosmetic Surgery and their employees, the treating technician and Dr. Obasi from any and all liability, damages, cost and expenses arising from or out of the use Phoenix-CO2 Laser for the vaginal health treatment. With all of the above information understood, I am choosing to be treated with the Phoenix CO2 Laser.

Pre-Treatment of Vaginal Rejuvenation:

• Two weeks prior to treatment patient must undergo screening for infection
  
  
• Patient must have had recent normal pelvic exam
  
  
• Prophylactic Antiviral as needed
  
  
• Schedule around menstruation
  
  
• Avoid intravaginal creams and lubricants 24 hours prior to treatment
  
  
• Avoid sexual intercourse 12 hours pretreatment
  
  
• Encourage patient to hydrate prior to treatment

I, will be undergoing a vein removal procedure that involves the use of laser application.

This consent is provided as a means of education for vein removal patients. The intent of this consent is to create an understanding between the provider and the patient as to the methods and risk involved 

in vein removal. It should be understood that laser ablation treatments may need to be repeated several times before complete satisfaction is achieved. No guarantees have been made to me regarding the outcome of the treatment or any improvements in my condition due to the procedure. I understand this treatment is entirely voluntary on my part. I hereby indemnify and hold harmless Noble Cosmetic Surgery and all individuals associated with Noble Cosmetic Surgery the physician and/ or the treating technician, and all staff members at the office from any and all liability, damages, cost and expenses arising from or out of the use of the Spectrum Laser System. I understand that there will be a charge for this and all consecutive treatments unless arrangements.

have been made otherwise. I understand that I am making a decision to undergo the treatment, described in the preceding sections and I am subject to the conditions of participation described above.

My below signature indicates that I have decided to receive the treatments, having read and understood this information presented above and having been given the opportunity to ask any questions that I might have about the procedure.

No guarantees have been made to me regarding the outcome of the treatment or any improvements in my condition due to the procedure.

These are the potential Risks:

1. Pain, burning, blister formation, and stinging sensation at the site of treatment.
   
   
2. Infection associated with the treatment site.
   
   
3. Pigmentary (color) changes at the treatment sites including decrease in skin color (Hypopigmentation or lightening) and/or increase in skin color (hyperpigmentation or darkening). 
   
   
4. Scar formation at the treated site.
   
   
5. Laser induced “cold sore like” blistering skin eruptions known as “herpetic” skin eruptions at the treatment site or surrounding tissue. 
   
   
6. Poor cosmetic outcome.
   
   
7. Recurrence of vessels at the treated sites.