Consent - UltraClear

Name*

First NameLast Name

PRE-TREATMENT INSTRUCTIONS

You MUST cease all bleaching, plucking/tweezing, waxing, threading/stringing, and electrolysis for 4 weeks prior to treatment
Avoid exfoliating products 1 week prior to treatment
You may be asked to stop any topical medications or skin care products prior to treatment
Avoid sun exposure and sun bed for 4 – 6 weeks prior to treatment. RECENTLY TANNED SKIN CANNOT BE TREATED. If treated within two weeks of active (natural sunlight or tanning booth) tanning, after treatment, you may develop burns that heal in hypo-pigmented white spots, and this may not clear for 2-3 months. In extreme cases, this may be permanent
The use of self-tanning products/bronzers must be discontinued one week before treatment. Any residual self-tanner must be removed prior to treatment or you will not be treated
Shave the area to be treated one day prior to treatment
If you have had a history of perioral or genital herpes simplex virus, antiviral therapy is recommended in order to prevent a breakout. Follow the directions for your particular antiviral medication
The treatment area should be clean of any perfume, deodorant, makeup, lotions, sun block, or any other chemical or skincare products

INTRA-TREATMENT CARE

At the beginning of every treatment session, we will review your medical status, and ask if there have been any changes. Please remember to inform us of any changes such as health, medications, and sun exposure. Changes may alter the effectiveness of treatment and may cause side effects and/or complications
The skin is cleaned prior to treatment
Topical anesthetics may be used to help with pain during the procedure
The technician may line the area with a white pencil in order to effectively treat you. This will wash off.
When treating the upper lip, the teeth can be protected with white gauze. The gauze also serves to support the lip during treatment allowing a surface to push against
Safety considerations are important during the procedure.
Some clients may feel a slight discomfort or pain after treatment sometimes described as an intense heat like a severe sunburn with excessive hyperpigmentation and/or redness and possible swelling.

POST-TREATMENT INSTRUCTIONS FOR 3DMIRACL™/SUPERFICIAL TREATMENTS

Do's and Don'ts

Immediately after the treatment, there may be swelling and redness in the areas that are treated. It is normal for the treated area to feel like an intense sunburn for up to 24 hours post treatment.
DO NOT ice your skin, NO ice baths for 72 hours, cold water is fine.
There are no restrictions on bathing except to treat the skin gently for the first 24 hours as if you have a sunburn, and to use cool water. Try to bathe prior to your treatment. Skin should be tapped dry and NOT rubbed. Rough towels and mechanical cleansing devices should not be used.
For a minimum of one week and while healing, please avoid any activity that will raise body heat. No strenuous activities, no hot tub, steam room, sauna, or hot showers
To avoid the possibility of infection, please make sure to sleep in an upright position with a clean pillowcase. Avoid laying flat, on your sides and/or on your face. Keep your skin clean. Be mindful of contact with cell phones, clothing, and people.
NO pets in bed or touching the treatment area
Avoid sun exposure and tanning for two months post treatment to reduce the chance of dark or light spots.
Avoid shaving until the skin has sloughed
Avoid picking or scratching the treated skin. During your treatments, DO NOT exercise any other facial, skin rejuvenation, CO2, IPL, Laser, or any other methods or products on the treated area.
NO waxing, NO threading/stringing, NO sugaring, NO plucking/tweezing, NO depilatory creams (nair, veet, etc.), NO shaving for 4-6 weeks post treatment.
Avoid alcohol, spicy foods or hot foods for 24 hours.
Avoid exercise, strenuous activity till redness or swelling subsides
Avoid the sun or any environmental exposures like wind, extreme cold, ocean water for 2 weeks post treatment.
Please do not scrub or exfoliate the skin. NO cleansers or products with acids, PEG’S, high alcohol content, botanicals or multiple ingredients.
Avoid cosmetics unless you have a new brush and products to avoid infection. You may use cosmetics 2-3 days post treatment. Frequent use of moisturizer is encouraged. Please make sure the moisturizer used does not have alpha-hydroxy acids, retinols, benzoyl peroxide or astringents

Aftercare Products

Soak gauze in sterile water and apply to the treatment area. Keep the gauze on the skin to cool down for 5-10 min. Apply a Vanicream Daily Facial Moisturizer or EltaMD Skin Recovery Serum keep the skin hydrated.
The next day after treatment, and for the next 7 days, remove residual lotion with a cool moist cloth. Use just your fingertips, tapping NO circular motions and NO rubbing during this time. DO NOT scrub treatment areas. Use a gentle cleanser like Vanicream Gentle Facial Cleanser or EltaMD Skin Recovery Foaming Cleanser and continue with moisturizer.
Vinegar soaks can be used for any discomfort. Mix 1 tsp of distilled vinegar with 16 oz of sterile water. Remove any products prior to vinegar soaks with a cool moist cloth. Reapply products after the soak. Repeat as needed. 3-5 times/day
Day 2 – if you need to go outside, please begin untinted sunscreen application but do not expose skin directly to the sun. We recommend a minimum of 40 SPF and recommend EltaMD UV Skin Recovery or EltaMD UV Restore Broad Spectrum. Please use sunscreen daily for a minimum of 1-2 months post treatment.
A clear fluid may be present in the treated areas and may create a crust (or scab) if the areas are not kept moist. Within about 2 days you may have an exaggerated tan with slight crusting that may last up to 2 weeks or more
Please continue skincare regimen for at least 7 days after treatment
Please do not hesitate to call or text us at (702) 823-0852 if you have any questions or concerns.

POST-TREATMENT INSTRUCTIONS FOR ULTRACLEAR™/ADVANCED TREATMENTS

Do's and Don'ts

Immediately after the treatment, there may be swelling and redness in the areas that are treated. It is normal for the treated area to feel like an intense sunburn for up to 24 hours post treatment. To reduce the discomfort and remove the heat, sterile water soaks are recommended.
DO NOT ice your skin, NO ice baths for 72 hours, cold water is fine.
There are no restrictions on bathing except to treat the skin gently for the first 24 hours as if you have a sunburn, and to use cool water. Try to bathe prior to your treatment. Skin should be tapped dry and NOT rubbed. Rough towels and mechanical cleansing devices should not be used.
For a minimum of one week and while healing, please avoid any activity that will raise body heat. No strenuous activities, no hot tub, steam room, sauna, or hot showers
To avoid the possibility of infection, please make sure to sleep in an upright position with a clean pillowcase. Avoid laying flat, on your sides and/or on your face. Keep your skin clean. Be mindful of contact with cell phones, clothing, and people.
NO pets in bed or touching the treatment area.
Avoid sun exposure and tanning for two months post treatment to reduce the chance of dark or light spots.
Avoid shaving until the skin has sloughed
Avoid picking or scratching the treated skin. During your treatments, DO NOT exercise any other facial, skin rejuvenation, CO2, IPL, Laser, or any other methods or products on the treated area.
NO waxing, NO threading/stringing, NO sugaring, NO plucking/tweezing, NO depilatory creams (nair, veet, etc.), NO shaving for 4-6 weeks post treatment.
Avoid alcohol, spicy foods or hot foods for 24 hours.
Avoid exercise, strenuous activity till redness or swelling subsides
Avoid the sun or any environmental exposures like wind, extreme cold, ocean water for 2 weeks post treatment.
Please do not scrub or exfoliate the skin. NO cleansers or products with acids, PEG’S, high alcohol content, botanicals or multiple ingredients.
Avoid cosmetics unless you have a new brush and products to avoid infection. You may use cosmetics 2-3 days post treatment. Frequent use of moisturizer is encouraged. Please make sure the moisturizer used does not have alpha-hydroxy acids, retinols, benzoyl peroxide or astringents

Aftercare Products

Soak gauze in sterile water and apply to the treatment area. Keep the gauze on the skin to cool down for 5-10 min. Apply EltaMD Laser Balm to keep the skin hydrated.
The next day after treatment, and for the next 7 days, remove residual lotion with a cool moist cloth. Use just your fingertips, tapping NO circular or RUBBING during this time. DO NOT scrub treatment areas. Use a gentle cleanser like Vanicream Gentle Facial Cleanser or EltaMD Skin Recovery Foaming Cleanser and continue with moisturizer.
Vinegar soaks can be used for any discomfort. Mix 1 tsp of distilled vinegar with 16 oz of sterile water. Remove any products prior to vinegar soaks with a cool moist cloth. Reapply products after the soak. Repeat as needed. 3-5 times/day
§ Day 2 – if you need to go outside, please begin untinted sunscreen application but do not expose skin directly to the sun. We recommend a minimum of 40 SPF and recommend EltaMD UV Skin Recovery or EltaMD UV Restore Broad Spectrum. Please use sunscreen daily for a minimum of 1-2 months post treatment.
A clear fluid may be present in the lasered areas and may create a crust (or scab) if the areas are not kept moist. Within about 2 days you may have an exaggerated tan with slight crusting that may last up to 2 weeks or more.
Please continue skincare regimen for at least 7 days after treatment
Please do not hesitate to call or text us at (702) 823-0852 if you have any questions or concerns

ACKNOWLEDGMENT: I acknowledge that I have had the opportunity to review the Client Care treatment Instructions prior to treatment.*

Client Signature

If minor, Parent/Legal Guardian Signature

We are committed to serving you with compassion, care, skill, and respect. As one of our clients, you have choices, rights, and responsibilities.

Client's Name*

First NameLast Name

I hereby authorize Simply Skin Las Vegas, its employees/agents/clinicians to perform UltraClear treatments on me. Treatment sites include face, forehead, mono-brow, sideburns, lip, chin, neck, arms, hands, fingers, thighs, legs, feet, toes, chest, abdomen, shoulders, back, buttocks.

The purpose of this procedure is to diminish or remove sun damage, fine lines, wrinkles, acne and/or acne scars an overall quality of the skin. I understand that I may require several treatments to obtain a significant, long-term effective. The total number of treatments will vary between individuals. I understand that genetics, hormones, medication, diet, allergies, and color of lesions may interfere with the treatment, and there are patients that may not respond at all, and/or patients – whose acne may come back.

I understand that the treatment is purely elective, and I hereby consent to be a patient receiving treatment. Alternative methods exist. I understand that certain complications are rare, but possible.

Other potential risks include itching, blistering, burns, infection, scabbing, and failure to achieve desired result.

The procedure may result in the following side effects or adverse experiences, and may carry some risks

DISCOMFORT – Some discomfort may be experienced during treatment
REDNESS/SWELLING/BRUISING – Short-Term/temporary redness (erythema), swelling (edema), and/or mild sunburn-like effects of the treated area is common and may occur. There also may be slight bruising. Treated areas will initially be bright red. After the first few days, you may put opaque makeup on over the redness. The redness should fade over the following weeks. Areas most likely to swell are around the eyes and neck.
SKIN COLOR CHANGES – I understand that immediately post treatment, my skin will become darker or a bronzing effect, and will eventually crust. The crust will shed on its own. I UNDERSTAND THAT I SHOULD NOT PICK IN ORDER TO AVOID SCARRING. There is a possibility that the treated area may become either darker (hyper-pigmentation) or lighter (hypo-pigmentation). These conditions usually resolve within 3-6 months, but permanent color change is a rare risk. Compliance with the aftercare guidelines and avoiding sun exposure before and after the treatment reduces the risk of color change.
WOUNDS – Treatment can result in burning, blistering, or pinpoint bleeding of the treated areas. If any of these occur, please contact our office immediately.
Persistent Pixel Stamping Marks (PPSM) - A novel complication of fractional laser resurfacing where the pixel marks can remain for weeks to months and sometimes be permanent
INFECTION/BREAKOUTS – Infection is a possibility whenever the skin surface is disrupted, although proper wound care should prevent this. If signs of infection such as pain, heat, or surrounding redness develop, please call our office immediately. If you have had a history of perioral or genital herpes simplex virus, antiviral therapy is recommended in order to prevent a breakout. Follow the directions for your particular antiviral medication.
SCARRING/HYPERPIGMENTATION/HYPOPIGMENTATION – Scarring is a rare occurrence, but it is a possibility if the skin surface is disrupted. To minimize the chances of scarring, it is IMPORTANT that you follow all post-treatment instructions provided by your healthcare staff. Compliance with the aftercare guidelines and avoiding sun exposure before and after the treatment reduces the risk of scarring.
ALLERGIC REACTIONS – In rare cases, local allergies have been reported.
Ectropion – In rare instances, a downward pull of the eyelids can result after periorbital laser resurfacing.
EYE EXPOSURE – Protective eyewear (shields) will be provided. Exposure of the laser to the eyes could harm vision. It is important to keep these shields on at all times during the treatment in order to protect your eyes from accidental laser exposure.

I am aware of the possible complications/risks involved with the procedure and subsequent healing period. *

Initials

I fully understand that it is impossible to make guarantees regarding the outcome of any cosmetic/medical treatment and/or procedure. I understand that clinical results may vary depending on individual factors, including but not limited to medical history, skin type, patient compliance with pre- and post- treatment instructions, and individual response to treatment. I acknowledge that no guarantees, either expressed or implied have been made to me regarding the outcome of any treatments and/or procedures.*

Initials

I understand that I am financially responsible for all amounts due for services rendered at the time of the treatment. I also authorize the release of information to a licensed physician of the facility’s choosing for the purposes of professional interpretation and establishment of treatment recommendations.*

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I understand that my procedure may involve a series of treatments*

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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.*

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I HAVE THE RIGHT TO:

Be treated with dignity and respect
Know the name(s) and professional status of the person(s) serving you
Privacy
Confidentiality of your records
Receive accurate information about your health-related concerns
Know the effectiveness, possible side effects and problems of all forms of treatments
Participate in choosing a form of treatment
Receive education and counseling
Consent to, or refuse any care or treatment
Review your medical record with your clinician
Amend your medical records
Receive any information about services

I ALSO HAVE THE RESPONSIBILITY TO:

Seek medical attention promptly
Be honest about your medical history
Ask about anything you do not understand
Follow health advice and instructions
Report any changes in health or medication
Respect our policies
Seek care during normal business hours and to provide useful feedback regarding our services and policies

If applicable, at the time of treatment, I can neither be pregnant nor nursing*

Initials

I have provided my past and current medical history and medications*

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I consent to the taking of photographs/video during the course of my laser therapy for healthcare records – we must be able to document any reactions, pre-existing marks in the area, etc. These will be unidentifiable and will remain with your medical records*

Initials

I consent to using my photographs/video for medical education and/or marketing purposes by Simply Skin Las Vegas and/or Acclaro Corporation and/or any party acting under their license and authority and/or their designees. Such photos may be published in any advertisements including any print, digital, visual, or electronic media, websites, social media including but not limited to training manuals, presentations and teaching courses, books, photo books, magazines, TV broadcasts.

Initials

ACKNOWLEDGMENT: I understand the information given to me and the risks that have been outlined. I will be given the opportunity to ask questions about the procedure during my consultation and will not proceed with treatment until my questions regarding the procedure and the risks associated have been answered satisfactorily. 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 with a complete understanding of the risks. *

Client Signature

If minor, Parent/Legal Guardian Signature