Diolaze XL Consent

Name*

First NameLast Name

Email

example@example.com

Please inform the provider(s) prior to treatment if you have any of the following conditions that may make you unsuitable for Diolaze XL treatments:

Under 18 years of age (unless there is parents consent)Pregnancy or nursingPacemaker or internal defibrillator or any electronic Implant such as glucose monitorPermanent implant in the treated area such as metal plates and screws, silicone implants or an injected chemical substanceCurrent or history of cancer, especially skin cancer, or pre-malignant molesImpaired immune system due to immunosuppressive diseases such as AIDS and HIV, or use of immunosuppressivemedicationsSevere concurrent conditions such as cancer, cardiac disorders, epilepsy, uncontrolled hypertension, and liver or kidneydiseasesA history of diseases stimulated by heat, such as recurrent Herpes Simplex in the treatment area (prophylactic treatment maybe given)Any active condition in the treatment area, such as sores, psoriasis, eczema and rash as well as excessively/freshly tanned skinHistory of skin disorders such as keloid scarring, abnormal wound healing, as well as very dry, cracked, ulcerated, infected andfragile skinTattoos, permanent make-up, pigmented lesions (to be kept)Any medical condition that might impair skin healingPoorly controlled endocrine disorders, such as diabetes or thyroid dysfunctionAny surgical, invasive, ablative procedure in the treatment area in the last 3 months or before complete healingUse of Isotretinoin (Accutane) within 6 months prior to treatment

This form is designed to give you the information you require to make an informed choice of whether or not to undergo treatment with DIOLAZE/DIOLAZEXL technology. If you have any questions before your treatment, please feel free to ask.

I hereby authorize providers at Brighton Aesthetics and Wellness Center to perform the Diolaze XL procedure.

I have received the following information about the technology:

DIOLAZE/DIOLAZEXL is a non-invasive technology that utilizes Diode laser, for hair removal with highest speed, the best skin cooling system for hairs of dark blond-black color.

No complete clearance is guaranteed.
Treatment requires a number of sessions.
Exact number of sessions is individual.
There may be some discomfort and transient redness and/or swelling associated with treatment.
There is a small risk of adverse reactions.

I understand that taking the treatment course is my choice and that I am free to withdraw at any time, without giving any reason.

I was told about the possible side effects of the treatment including: local pain, skin redness (erythema), swelling (edema), damage to the natural skin texture (crust, blister, burn), change of pigmentation (hyper- or hypo-pigmentation), and scarring. Although these effects are rare and expected to be temporary, any adverse reaction should be reported immediately.

I understand that I have to comply with treatment schedule, otherwise results may be compromised.

I recognize that during the course of the procedure unforeseen conditions may necessitate different procedures than this above and I authorize the physician or assistants to perform such other procedures if they find them professionally desired.

I understand that not everyone is a candidate for this treatment and results may vary therefore, there is no guarantee as to the results that may be obtained.

Consent for Before/After Photographs

I consent to photographs being taken to evaluate treatment effectiveness for medical education and to track treatment progress. No photographs revealing my identity will be used without my written consent.

I have read the “Before and After Instructions” and understand to my satisfaction the procedure, potential benefits and risks, and before and after care instructions. I freely consent to the proposed treatment. I certify that I am a competent adult of at least 18 years of age, or that if I am a minor under the age of 18, I understand that the consent of my parent/legal guardian/person having legal custody will also be required before treatment.

ACKNOWLEDGMENT

BY MY SIGNATURE BELOW, I ACKNOWLEDGE THAT I HAVE READ AND FULLY UNDERSTAND THE CONTENTS OF THIS INFORMED CONSENT FOR THE LASEMD TREATMENT, AND THAT I HAVE HAD ALL MY QUESTIONS ANSWERED TO MY SATISFACTION BY MY HEALTHCARE TEAM.

Signature

Date

Diolaze XL Hair Removal Consent