IPL Informed Consent

Acknowledgements:

• I understand the below list of short term effects and agree to follow matching guidelines: 1) Flaking of pigmented lesions may take 5-10 days to disappear and it is important NOT to manipulate or pick which may otherwise lead to scarring. 2) 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 "sunburn" sensation may follow for typically one hour and will be reduced with application of cooling and soothing creams. 3) Reddening & swelling - severity and duration depend on the intensity of the treatment and the sensitivity of the area treated. These phenomena may be reduced with application of cooling and/or anti-inflammatory creams. 4) 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 postcare instructions and may increase the chance of complications.
• The procedure as well as potential benefits and risks have been thoroughly explained to me and I have had all my questions answered.

• Pre and post-care instructions have been discussed and are completely clear to me.
• I understand that there is a rare possibility of side effects or serious complication including permanent discoloration and scarring. I am aware that careful adherence to all advised instructions will help reduce this possibility.
• 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 treatment and be kept solely in my medical record.
• 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.

Do any of the following conditions/situations apply to you?

• Have you had ocular surgery or eyelid surgery, within 6 months prior to your first IPL session?
• Neuro-paralysis in the planned treatment area, within 6 months prior to your first IPL session?
• Uncontrolled eye disorders affecting the ocular surface, for example active allergies?
• Pre-cancerous lesions, skin cancer or pigmented lesions in the planned treatment area?
• Do you have any uncontrolled infections or uncontrolled immunosuppressive diseases?
• Ocular infections, within 6 months prior to the first IPL session?
• History of migraines, seizures or epilepsy?
• Have you had any natural or artificial sun exposure in the past 3-4 weeks? Do you plan to have any exposure in the 3-4 weeks post procedure? Have you used self-tanners or enhancer caps in the past 3-4 weeks?
• Have you used photosensitive herbal preparations (St. John's Wort, Ginkgo Biloba, etc) or aromatherapy (essential oils)?
• Do you have any diseases which may be stimulated by light at 400nm - 1200 nm, such as Systemic Lupus Erythematosus or Porphyria?
• Are you pregnant, possibly pregnant, post-partum or nursing?
• Do you have any inflammatory skin conditions?
• Do you have any present or a history of active cold sores or herpes simplex virus?
• Have you been diagnosed with HIV?
• Do you have active cancer with current chemotherapy or radiation treatment?
• Do you have a history of skin cancer? keloids?
• Have you used Isotretinoin (accutane) or other medication that can create light sensitivity in the last year?
• Do you have a medical history of Koebnerizing Isomorphic Diseases (vitiligo, psoriasis)?
• Do you have any known allergies?
• Do you have any tattoos or pigmented lesions on the requested treatment area that should be protected?
• Do you have any hormonal or endocrine disorders (PCOS or uncontrolled diabetes)?
• Do you have any hair on the requested treatment area that should not be removed?
• Have you had any previous skin procedures on the requested treatment area (Botox, fillers, peels, etc)?
• Do you currently take aspirin, anti-coagulants or bruise easily?
• Do you use any skin creams or serums which contain retinol?