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Home » Contact Us » IPL Consent Form

IPL Consent Form

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Located at 1216 Village Market Pl, Morrisville, NC 27560

  • Please read and initial each statement.Complete, underline or circle individual selection accordingly
    • 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
  • HR PL SR VL
  • HR
  • PL SR VL
  • PL SR
  • SR VL
  • 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 treatments
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY