IPL Consent Form Located at 1216 Village Market Pl, Morrisville, NC 27560 Please read and initial each statement.Complete, underline or circle individual selection accordinglyI authorize Dr. Hiten Prajapati to perform IPL™treatments on me in an effort to improve Dyschromia Hyperpigmentation Hair Reduction PWS Haemangioma Angioma Rosacea Telangiectasia I understand that there is a rare possibility of side effects or serious complications including permanent discoloration and scarring. I am aware that careful adherence to all advised instructions will help reduce this possibility I understand the below list of short-term effects and agree to follow matching guidelines: Flaking of pigmented lesions – crusts may take 5 to 10 days to disappear and it is important not to manipulate or pick which may otherwise lead to scarring Discomfort – during the procedure, I might experience a sensation similar to a rubber band snap which degree will vary per my skin condition and area sensitivity but that does not last long. A mild “sun-burn” sensation may follow for typically up to one hour and will be reduced with application of cooling and soothing creams Reddening and swelling – severity and duration depend on the intensity of the treatment and the sensitivity of the area to be treated. These phenomena may be reduced with application of cooling and/or anti-inflammatory creams Bruising may rarely occur and may last up to 2 weeks I understand that sun exposure or tanning of any sort is not aligned with the pre and/or post-care instructions and may increase the chance for complications The procedure as well as potential benefits and risks have been thoroughly explained to me and I have had all my related questions answered Pre and post-care instructions have been discussed and are completely clear to me I understand that results may vary with each individual and acknowledge that it is impossible to predict how I will respond to the treatment and how many sessions will be required I consent to photographs being taken for the purpose of documenting my progress and response to the treatment and be kept solely in my medical record I consent to photographs being used for medical education or publication with applied discretion and not revealing my identity I agree to review the following IPL™ pre-treatment compliance checklist along with my Physician and bring accurate and updated data, to the best of my knowledge Skin type of the area to be treated: 1 2 3 4 5 6 HR PL SR VL Natural or artificial sun exposure in the past 3-4 weeks pre-op or the following 3-4 weeks post-op plan Yes No Use of self–tanners or tan enhancer caps within the past 3-4 weeks pre-op plan Yes No Photosensitive herbal preparations (St John’s Wort, Ginkgo Biloba, etc…) or aromatherapy (essential oils) Yes No Yes Diseases which may be stimulated by light at 400 nm to 1200 nm, such as history of Systemic Lupus Erythematosus or Porphyria Yes No Yes Pregnant or possibility of pregnancy, postpartum or nursing Yes No Inflammatory skin conditions (dermatitis, etc...) Yes No Yes Presence or history of active cold sores or herpes simplex virus Yes No HIV Yes No Active cancer (currently on chemotherapy or radiation) Yes No Previous skin cancer? Yes No Medical history of keloids Yes No Intake of isotretinoin within the past year Yes No Medical history of Koebnerizing isomorphic diseases (vitiligo, psoriasis) Yes No Yes Any known allergy? Yes No Yes Any tattoo and/or pigmented lesion on requested treatment area that should be protected? Yes No List of additional current medication takenHRHormonal or endocrine disorders (PCOS or uncontrolled diabetes?) Yes No Yes Previous hair removal procedures on requested treatment area (other IPL/laser, wax, electrolysis, etc…) Yes No Yes: what/when? PL SR VL Any observed modification (colour, size, texture and border) on the lesion to be treated? Yes No Yes Any hair on requested treatment area that should not be removed? Yes No Age of lesion onset? PL SR Previous skin procedures on requested treatment area (Botox, fillers, peels, etc...) Yes No Yes: what/when? SR VL Intake of aspirin or anti-coagulants? Yes No Yes Easy bruising? Yes No My signature certifies that I have duly read and understood the content of this informed consent form, and gave the accurate information as to my health condition. I hereby freely consent to M22™ IPL skin treatmentsName of patient First Last Signature of patientDate MM slash DD slash YYYY Name of witness First Last Signature of witnessDate MM slash DD slash YYYY
