Ultra LaseMD Treatment Consent Form

CONTRAINDICATIONS FOR ULTRA TREATMENT: 

• Allergies to local anaesthetic, lidocaine, antibiotics, and other medication. 
• Healing disorders and history of keloid scarring. 
• Diseases stimulated by light, such as Epilepsy. 
• Diabetes. 
• History of cancer, current cancer, pre-cancerous lesions, and pre-malignant moles. 
• Radiation and chemotherapy. 
• History of recurrent herpes and active Herpes Simplex, pre-treatment with anti-viral medications is recommended. 
• Pregnancy. 
• Metal implants in the area treated. 
• Fragile, dehydrated skin. 
• Active skin conditions in the area treated, such as psoriasis and eczema, sores, and rash. 
• Recent surgical procedures in the area treated within three months or before complete healing. 
• Tattoos and permanent makeup. 
• Excessively tanned skin from sun or tanning beds within the last 2 weeks. 
• Vitiligo. 

EXCLUSION CRITERIA FOR ULTRA TREATMENT: 

• Sauna or Hammam Scrub 72 hours before the treatment. 
• Facial resurfacing, chemical and mechanical peels in the area treated within the last 2 weeks. 
• Injections of filler within the last 2 weeks. 
• Injections of botulinum toxin within the last 2 weeks. 
• Application of essential oils 15 days before the treatment session in the area treated. 
• Use of active ingredients 48 hours before the treatment. 
• Tanning creams within the last week. 
• Use of isotretinoin (Accutane) within 6 months prior to the treatment). 

SIDE EFFECT: 

• Erythema (redness): The treatment area may present erythema immediately after the treatment, which usually resolves within 24 hours depending on skin sensitivity. Recent Retinol, vitamin C, glycolic and salicylic acid use may produce more pronounced redness. 
• Oedema (swelling): The treatment area may present mild oedema following the treatment. This typically resolves within few hours or few days after the treatment. Improper topical anaesthetic cream cleaning may result in prolonged oedema and erythema. 
• Pain: Momentary discomfort may be experienced during the procedure. Moderate to strong burning sensation might be felt after the treatment and usually resolves within one to two hours. 
• Scarring: The possibility for scar formation is possible if went over the keloid scar tissue. 
• Skin sensitivity: Use of active ingredients such as Retinol may increase skin sensitivity and should be avoided a few days prior to the treatment and 7 days post treatment. 
• Micro impact points might be felt up to 5 days following the treatment. 
• Skin might appear dry for up to 10 days following the treatment. 

POST TREATMENT GUIDELINES: 

• Cold air can be used post treatment to reduce discomfort. 
• If patient has recurrent herpes simplex, antiviral medication may be prescribed a day before the treatment following 6 days after the treatment. 
• Sterile soothing cream and sun protection must be applied on the area treated for at least two to three weeks. 
• Do not apply anything on the skin 2 to 3 hours after the treatment. 
• Tiny scabs formed after the treatment must not be touched or scratched. 
• Avoid hot baths, showers, sauna, and swimming pools 72 hours after the treatment. 
• Avoid exercising 72 hours after the treatment. 
• No makeup can be applied at least 24 hours post treatment. 
• Avoid sun exposure for at least a month after the treatment. 
• No exfoliation of the skin until complete healing. 
• Lase MD ampoule must be used morning and night post treatment session. 
• Skin must be cleansed before applying the Lase MD ampoule. 
• Ampoules must be kept in a fridge for up to 15 days post treatment. 
• Do not used any oil-based creams during the healing period after the ULTRA treatment.
• Water based cosmeceutical should be used during healing period.

I understand that ULTRA™ treatment is intended for treatment of skin rejuvenation, wrinkles, acne scars, skin tone and skin texture and that treatment is commonly performed over facial and nonfacial areas.

• Herpes Simplex – Herpes simplex eruptions may occur in rare cases in a treated area that has previously been infected with the virus. This reactivation can be avoided by taking an anti-viral medication prior to the procedure, for which I can get a prescription from this office by request.
• Pain - Some patients feel a burning sensation from each laser pulse, which may produce a moderate to severe amount of discomfort. This mild burning sensation is similar to a sun-burn and may last for up to 24 hours post treatment.
• Redness and Swelling - Immediately after treatment your skin will be red and feel hot. This is temporary but may last for the first few days. The first day after treatment your treated area will be swollen and for the next few days the treated area will be red in color. After the first day, the redness can be camouflaged with opaque makeup. Cold packs can reduce these symptoms as will daily use of an antihistamine until they resolve.
• Hyperpigmentation - The treated areas will probably heal without any pigment changes. However, there is always the chance that hyperpigmentation (skin darkening) may occur. These are temporary conditions and will fade within 2 – 6 months. Avoid sun exposure before and after treatment as exposure to the sun may intensify the pigment changes. It is rare that this change is permanent.
• Blistering or Scarring - Blistering occurs occasionally and needs to be reported to the office for additional post care instructions. Scarring is very rare and can be avoided by following all the posttreatment instructions carefully.

I understand that clinical results may vary depending on my response to surgery and my compliance with pre- and post-treatment instructions.

I understand that no guarantee has been given to me regarding the percentage of improvement of my skin and that more than one treatment is recommended to achieve the desired results.

I have read and understand this form and my questions have been addressed and answered to my satisfaction. I have read the pre-treatment considerations and post-treatment instructions and I will follow the recommendations outlined to protect my skin.