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CONSENT FOR TREATMENT OF VASCULAR LESIONS FOR CANDELA VBEAM LASER

The Candela VBeam Laser is a device that produces an intense but gentle burst of light that treats the abnormal blood vessels seen in spider veins or other cutaneous vascular lesions without harming the surrounding tissue.

To protect my eyes from the intense light, I will have my eyes covered with an opaque material or wear protective glasses.

Other methods of treating this type of lesion, such as sclerotherapy for leg veins or another therapy for vascular lesions have been discussed with me.

I have been informed that scarring, blistering, bruising, hypopigmentation (decreased color) or hyperpigmentation (increased color) are possible risks and complications of the procedure.

Depending on the size and color of the lesion being treated, complete clearing may not be possible or it may take multiple treatments for best results.

Anesthesia is usually not necessary. lf the physician or I elect to use a form of anesthesia, all options will be discussed with me in advance.

I consent to the taking of photographs during the course of my laser therapy for the purpose of medical education as well as to track progress of the lesions.

I understand that immediately following the laser treatment the area may appear as a red or bruised discoloration and may also be slightly swollen. I understand any discoloration may last 7-14 days and the swelling may last anywhere from 1-24 hours. lmproper care of the treated area while the discoloration is present may increase the chance of scarring or skin textural changes to the treated area.

I hereby authorize and any other associates or assistants selected to treat me using the Candela VBeam laser for vascular or other lesions. I understand that the treatment may not be 100% effective and that multiple treatments may be necessary.

I CERTIFY THAT I HAVE READ ANO FULLY UNDERSTAND THE TERMS ANO WORDS WITHIN THE ABOVE CONSENT TO THE PROCEDURE AND TO THE EXPLANATIONS REFERRED TO, OR MADE. I HAVE HAD THE OPPORTUNITY TO ASK ANY QUESTIONS REGARDING THE PROPOSED TREATMENT. I ALSO CERTIFY THAT I READ AND WRITE IN ENGLISH.

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May 6, 2020 3:22 pm MST

Consent for Treatment of Vascular Lesions Uploaded by Dermatology Partners Inc - ilan@ntmatter.com IP 181.166.195.138