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Home » Patient Center » Intense Pulsed Light (IPL) / RadioFrequency (RF) Consent Form

Intense Pulsed Light (IPL) / RadioFrequency (RF) Consent Form

I consent to authorize Clariti Medspa & Wellness to perform Laser/IPL/RF treatments on me. Light can be used effectively to destroy targets located in the skin with minimum damage to the surrounding tissues. Light is used to lighten, fade or remove photodamaged skin, veins, and/or tattoos in a non-ablative manner. Visible signs of photodamage include wrinkling, enlarged pores, course skin texture, and pigment alterations.

I certify that I do not have any of the following conditions which are CONTRAINDICATIONS to laser treatment: history of melanoma, raised moles, suspicious lesions, keloid scar formation, active infections, open lesions, hives, active herpetic lesions, tattoos or permanent makeup in an area of treatment, use of medications such as Accutane, Tetracycline, or St. John’s Wort in the last year, autoimmune diseases such as lupus, scleroderma, vitiligo, or have used sunless tanning products in the last 10 days.

I certify that I am not pregnant, trying to get pregnant or nursing. I have informed my technician of my recent sun exposure and if I have had any, I understand the risks of skin discoloration with treatment. Photo therapy, despite its high levels of efficacy and safety, is not free of side effects. Erythema (redness) and edema (swelling) of the treated area can occur but usually subsides within a few hours, but can last up to seven days or longer. Irritation, itching, and/or a mild burning sensation or pain (similar to a sunburn) may occur within 48 hours of treatment.

I understand that the treatment may be painful, but this is typically managed without any pain medications. Pigment changes, such as hyperpigmentation or hypopigmentation, of the skin in the treated areas can occasionally occur.

Most often, it is transient, lasting up to six months, but in rare cases can be permanent. Most cases of hyper- or hypo- pigmentation occur in people with darker skin or when the treated area has been exposed to sunlight before or after a treatment. Occasionally, these pigment changes can occur despite appropriate protection from the sun.

Unprotected sun exposure in the weeks following treatments are contraindicated as it may cause pigmentation changes or worsen the condition. Scarring, which can be hypertrophic or even keloid, can occur.

Other known complications of this procedure include blisters, reddening, pinpoint pitted scars, bruising, superficial crusting, burns, pain, and infection.

These side effects are usually temporary, lasting from five to ten days but can be permanent as well. The skin at or near the treatment site may become fragile. If this happens, makeup should be avoided and the area should not be rubbed, as this might tear the skin. A blue-purple bruise may appear on the treated areas, which might last several days. As the bruise fades, there may be rust-colored brown discoloration of this skin, which typically fades in one to three months.

Additionally, there is a known and expected loss of hair the treated areas. In a very small percent of people, there is new hair growth in the surrounding areas being treated. Even though appropriate measures are taken to reduce side effects, they cannot be completely eliminated in every case.

I understand that the treatment may involve risks of complications or injury from both known and unknown cases, and I freely assume all risks. There may be other treatment options, such as injections, other types of laser/light therapy, or chemical peels.

With this in mind, I am choosing this non-invasive treatment for vascular and/or pigment lesions and/or tattoo removal and other indicated skin conditions. Eye damage can occur from the light and therefore protective eyewear must be worn during all phototherapy sessions.

  • I have read and understand the Pre- and Post- treatment instructions.
  • I agree to follow these instructions carefully.
  • I understand that compliance with recommended pre and post procedure guidelines are crucial for healing, prevention of scarring, and other side effects and complications, such as hyperpigmentation, hypopigmentation, and other textural changes.
  • I understand that this treatment is not meant to replace the necessity for a complete dermatological examination. No guarantee, warranty, or assurance has been made to me as to the results that may be obtained.
  • I am aware that follow-up treatments may be necessary for desired results. Most clients require a number of treatments over several months with gradual results occurring over this time.
  • I agree to adhere to all safety precautions and regulations during the treatment. No refunds will be given for treatments received. The nature and purpose of the treatment has been explained to me.
  • I have read and understand this agreement. All of my questions are answered to my satisfaction and I consent to the terms of this agreement.
  • Alternative methods of treatment and their risks and benefits have been explained to me and I understand that I have the right to refuse treatment.
  • I release Clariti Medspa & Wellness, staff, and specific technicians from liability associated with this procedure.
  • I certify that I am a competent adult of at least 18 years of age.