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Clear and Brilliant Consent

The nature of the CLEAR + BRILLIANT TM laser system procedure has been explained to me. I understand that just as there may be benefits from the procedure, all procedures involve risk to some degree.

Clear and Brilliant is our minimally invasive skin refreshing laser. The laser energy creates millions of microscopic treatment zones in your skin, replacing damaged tissue with healthy, younger looking skin. The treatment not only improves signs of aging, it gives you:

More even, uniform tone
Renewed, ultra-soft and smoother texture
Naturally radiant and glowing skin

The treatment is performed by our aestheticians. There is typically no down time to this procedure. Patients may feel a little red or sunkissed the day of the procedure, but side effects subside hours after treatment.

EXPLANATION OF PROCEDURE

The treatments are spaced apart every 4 weeks for 4-6 treatments. Please come with no make-up, including no eyeliner, mascara, or lipstick. The procedure itself takes 15 to 45 minutes depending upon the size of the treatment area. The sensation during treatment may range from prickly, rubber band snapping, to a burning/heat sensation. Following your treatment, you will experience varying degrees of redness, swelling and heat, similar to a mild sunburn. Light peeling/flaking of the skin may also occur. These common side effects last from several days to a couple of weeks, depending upon the aggressiveness of the treatments.

I understand that the following are among the possible risks or complications associated with the CLEAR + BRILLIANT ™ laser system procedure:

Eye injury- Eye injuries may result from either numbing cream getting into the eyes, or the laser beams. Do not rub your eyes while the numbing cream remains on your face. Your eyes will be covered with protective goggles and should remain closed during the treatment.

Bleeding - The laser treatment may cause some bleeding. lt is usually pin-point (petechiae), does not reach the upper level of the skin, and stops within a few minutes without any lasting effect. Occasionally bleeding may occur on a larger scale (purpura). The redness will darken to purple and purple-yellow and will disappear in one to two weeks.

Pigment Changes - During the healing phase (up to 6 months after the treatment), the treated area may appear to be darker. This is called PIH, post inflammatory hyperpigmentation. You may have experienced this type of reaction before and noticed it with minor cuts or abrasions. PIH occurs as part of normal skin reaction to injury, as the skin functions become hyperactive during the healing process, including cells that produce pigments (melanocytes). Not surprisingly, PIH occurs more frequently with darker skin-colored patients, or patients already with a tan.

To reduce the risk of PIH, the treated area must be protected from exposure to the sun. However in some patients, increased skin coloring occur even if the area has been protected from the sun. This darker pigmentation usually fades in three to six months. In extremely rare cases, the pigment change could be permanent.

In some patients who experience pigmentary alteration, the treated area loses pigmentation and becomes a lighter color than the surrounding skin. This type of reaction may also be permanent.

Blistering, Scabbing, and Scarring- The CLEAR + BRILLIANT procedure produces heating in the skin. Excessive heat may cause separation between upper and middle layers of the skin, resulting in blister formation. Blisters usually collapse within a couple of days and may form scabs. Scabs may fall off without complications in 2 - 4 days; however, they may also lead to scarring, including raised scars. Scarring may lead to permanent loss of pigment in the scarred area.

lnfection - lf blisters or bleeding are present, an infection of the wound is possible. Any blistering or bleeding must be dressed with an antibiotic ointment and covered. Secondary infection of the blisters could lead to scarring.

lt is important to strictly follow all post-treatment instructions.

Efficacy- Because all individuals are different, it is not possible to completely predict who will benefit from the procedure. Some patients will have very noticeable improvement, while others may have little or no improvement. lt is possible that additional treatments may be needed to achieve the desired end result, or that smaller touch-up procedures may be required.

I am aware that other unexpected risks or complications may occur and that no guarantees or promises have been made to me concerning the results of the procedure. It has also been explained that during the course of the proposed procedure, unforeseen conditions may be revealed requiring performance of additional procedures. My questions regarding this treatment, its alternatives, its complications and risks have been answered by my doctor and/or his or her staff.

DO NOT SIGN THIS FORM UNLESS YOU HAVE READ IT AND BELIEVE THAT YOU UNDERSTAND IT. ASK ANY QUESTIONS YOU MIGHT HAVE BEFORE SIGNING THIS FORM. DO NOT SIGN THIS FORM IF YOU HAVE TAKEN MEDICATIONS WHICH MAY IMPAIR YOUR MENTAL ABILITIES OR IF YOU FEEL RUSHED OR UNDER PRESSURE.

I have read this form and understand it, and I request the performance of the procedure.

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May 14, 2020 11:57 am MST

Clear and Brilliant Consent Uploaded by Dermatology Partners Inc - ilan@ntmatter.com IP 181.166.195.138