ACNE Consent Form: V-Carbon 

I DECLARE:

• That I have been thoroughly informed on the nature and on the known effects of the medical operation requested and described below.
• That I am aware that this consent is personal and not delegable to relatives (if not underage or under guardianship
• That I have agreed upon the selection of the treatment and on the type of medical device after a scrupulous and thorough explanation on the pre-treatment conditions and on therapeutic alternatives
• That Bella Day Spa LLC has supplied me with all the information and indications concerning the precautions and warnings to follow in the days before and after the treatment with the aim of favoring a normal healing process and to avoid complications and/or to not invalidate the good outcome of the treatment itself.
• That I have been informed on the possibility that if the precautions and warnings are not followed, I could jeopardize the outcome of the treatment. In order to avoid the latter, I will commit to following all the indications I am supplied with during and after the treatment, and in particular:
• That I am aware of the necessity to avoid the sun and tanning with UVA lamps after the treatment.
• That I have been informed that the therapy proposed presents the following indications:

INDICATIONS:

• Actinic keratosis,
• Pigmentary dyschromia,
• Depressed superficial wrinkles and scars.
• Cheek and eye contour superficial wrinkles
• Photoaging (cutaneous aging)
• Atonic and greyish skin
• Acne scars
• Stretch marks
• Attenuation of skin spots
• Acne in a comedogenic and microcyst phase
• Seborrheic dermatitis
• Radiodermatitis

CONTRAINDICATIONS:

• Insulin-dependent diabetes
• Cardiopathy
• Nephropathy
• Cutaneous eruptions such as herpes
• Pustular acne in an active phase
• Pregnancy
• Unreal expectations
• Herpes simplex in an active phase
• Atopic dermatitis
• Patient's refusal towards photo-protection
• Melasma (frontal, cheek hyperpigmentation as a consequence to the use of antibiotics, pregnancy, contraceptive pills)
• Chronic urticaria

SIDE EFFECTS:

• Relapsing herpes

• Skin redness and darkness for a few days after the treatment, and the exfoliation of the latter for about 8-10 days.

• Allergic reaction (very rare, but may occur)

• Retinoid dermatitis (cutaneous inflammatory response

 

In the 2-3 days after the treatment, it is suggested to completely avoid the exposure to too warm or too cool temperatures. In the post-peeling course, it is essential to protect oneself from the sun and from UVA-UVB rays for at least two months, with the use of products containing protective sun filters and shields with the aim of preventing eventual post-inflammatory hyperpigmentations. Skin must not be irritated for at least 1 month (dermal-abrasions, irritating treatments and any treatments on exposed areas must be authorized by the doctor

Possible problems: frost effect with possible formations of small crusts, hypo or hyperpigmentations, and some patients may not respond to the treatment or obtain modest results.

Results are not definitive but are to be considered a helpful method to maintain skin healthy.

In modern Aesthetic Medicine, the use of Peelings is often combined to other therapies in order to obtain an efficient Biorevitalization of the areas treated.

The procedures and the equipment used are currently considered the most appropriate from a medical-scientific point of view.

I declare that I am not pregnant

I am aware that the percentage of improvement of the defect to correct, the entity, the tolerability of the substance and its duration, the symmetry of the result, do not only depend on the techniques used and on the filling substances used, but also on the organism's response. I declare that I am aware that the practice of Medicine and Surgery does not constitute the expression of an exact science and I am aware that no warranty may be given to me in relation to the achievement of the aims anticipated by the procedure proposed. In case of dispute of the medical operation or for any controversy concerning the professional performances carried out, regarding the abovementioned method, the parts will renounce from judicial actions by now and will opt for an arbitration. I also understand the possibility that, during the course of the operation, unpredictable and unexpected situations may be verified, such to request the actuation of procedures not expressly stated in this document or the modification of the part for which this document has been elaborated. These procedures, necessary to bring back the general or local situation to optimal conditions, will be realized with the only aim of completing the treatment in the best way. I therefore authorize to realize these procedures in case, according to his/her experience, training and judgment, they were to be retained necessary, always operating with diligence, prudence and ability.

I declare that I have received all the necessary and exhaustive information concerning this form, that I have asked all the questions that I considered opportune and that I have received clear and thorough responses that I have understood and that on the basis of the information and clarifications received, I accept the treatment proposed.

I AUTHORIZE:

Bella Day Spa LLC to take pre-treatment pictures that will be exclusinvely used for popular/scientic purposes.

I AUTHORIZE:

Bella Day Spa LLC to realize the treatment proposed and described above.

I confirm that I have read and understand the abovementioned.

I confirm that I have had the possibility to ask all the questions that I considered necessary.

Taken note of the situation illustrated, I ACCEPT the medical procedures proposed