Dermatology Partners

Patient Consent Form For Treatment with The Cutera XEO Laser


Patient Consent Form For Treatment with The Cutera XEO Laser

I hereby authorize or any designated associates to provide treatment using the CUTERA XEO laser system. I consent to having the following treatment performed (circle treatments that apply):

  • TREATMENT OF VASCULAR AND PIGMENTED LESIONS- The procedure involves using a laser or pulsed light device to coagulate the vessels or vascular lesions. Light based devices will not prevent you from developing new veins. Although these devices are effective in most cases, no guarantees can be made.
  • TITAN- The procedure works by creating a thermal response in the dermis that induces collagen contraction and stimulates new collagen. There is little or no downtime associated with this treatment.
  • LASER GENESIS SKIN THERAPY- The procedure works on promoting vibrant and healthy looking skin by creating a thermal response in the dermis that stimulates new collagen.

I am aware of the following possible risks associated with the procedure(s):

  • DISCOMFORT- Some discomfort may be experienced during treatment.
  • REDNESS/SWELLING/BRUISING- Short term redness (erythema) or swelling (edema) of the treated area is common and may occur. There may also be some bruising.
  • PIGMENT CHANGES (SKIN COLOR CHANGES)- During the healing process, there is a possibility that the treated area can become either lighter (hypopigmentation) or darker (hyperpigmentation) in color compared to the surrounding skin. This is usually temporary, but in rare instances it may be permanent.
  • WOUNDS- Treatment can result in burning, blistering, or bleeding of the treated area. lf any of these occur, please call our office.
  • INFECTION- Infection is a possibility whenever the skin surface is disrupted, although proper wound care should prevent this. lf signs of infection develop, such as pain, heat, or surrounding redness, please call our office.
  • SCARRING- 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 the post-treatment instructions carefully.
  • EYE EXPOSURE- Protective eyewear (shields) will be provided. lt is important to keep these shields on at all times during the treatment in order to protect your eyes from injury.

The following points have been discussed with me:

  • Potential benefits of the proposed procedure
  • Possible alternative procedures
  • Probability of success- it is possible that the results will be minimal or not help at all
  • Reasonably anticipated consequences if the procedure is not performed.
  • Most likely possible complications/risks involved with the proposed procedure and subsequent healing period
  • Post -treatment instructions
  • For women of childbearing age: By signing below I certify that I am not pregnant. Furthermore, I agree to keep the office informed should I become pregnant during the course of treatment.

BY SIGNING BELOW, I CERTIFY THAT I HAVE READ ANO FULLY UNDERSTAND THE CONTENTS OF THIS CONSENT FOR TREATMENT AND THAT THE DISCLOSURES REFERRED TO HEREIN WERE MADE TO ME.

 

Date:

 

Leave this empty:

Dermatology Partners https://dermatologypartnersinc.com
Signature Certificate
Document name: Patient Consent Form For Treatment with The Cutera XEO Laser
Unique Document ID: b2b4659acb032be04c45c06c80a108bf1cc046f3
Timestamp Audit
May 6, 2020 3:37 pm MDTPatient Consent Form For Treatment with The Cutera XEO Laser Uploaded by Dermatology Partners Inc - ilan@ntmatter.com IP 181.166.195.138