Excel V Consent

I hereby authorize CCS Laser Rejuvenation, LLC to remove or lighten the appearance of vascular and/or pigmented lesions and/or stimulate collagen production. The procedure involves using a laser or pulsed light device to coagulate the vessels or vascular lesions and/or treat pigmented lesions, age spots, and sun spots by melanin absorption, and/or stimulate collagen regrowth. I understand it may take multiple treatments to obtain optimal results. Although these devices are effective in most cases, no guarantees can be made. I understand I may not experience complete clearance, and that it may take multiple treatments. Some conditions may not respond at all, and in rare cases, may worsen.

The procedure may result in the following adverse experiences or risks:
• DISCOMFORT/PAIN- Some discomfort may be experienced during treatment. Pain may include the feeling of burning, stinging, and radiating pain.
• REDNESS/SWELLING- Short term redness (erythema)is common and swelling (edema) of the treated area may occur. An urticarial (hive-like) reaction may occur with smaller vessels.
• PURPURA/BRUISING- Purpura (bruising) is a transient phenomenon that usually resolves with time.
• HEMOSIDERIN STAINING- Iron leaking into tissue from blood breakdown may occur and usually resolves over time but may be permanent.
• SKIN COLOR CHANGES- During the healing process, there is a slight possibility that the treated area may be become either lighter (hypopigmentation) or darker (hyperpigmentation) in color compared to the surrounding skin. This is usually temporary, but on a rare occasion, it may be permanent.
• EPIDERMAL CRUSTING- Pigmented lesions may crust as part of the healing process. Epidermal crusting may develop over vascular lesions. It is important not to disturb the crusts. Crusts will typically slough 7-14 days after treatment.
• WOUNDS- Treatment can result in burning, blistering, or bleeding of the treated areas. If any of these occur, please call our office.
• BURNS and INFECTION- Infection is a rare possibility whenever the skin surface is disrupted, though proper wound care should prevent this. If 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’s surface is disrupted. To minimize the chance of scarring, it is IMPORTANT that you follow all post-treatment instructions provided by your healthcare staff.
• TEXTURAL CHANGES/CUTANEOUS INDENTATIONS- May occur as a result of heat diffusion and thermal injury to tissue surrounding vessels.
• UNDESIRABLE HAIR REDUCTION- Hair reduction may occur at treatment sites. This is usually temporary but may be permanent.
• SUN EXPOSURE/TANNING BEDS/ARTIFICIAL TANNING- May increase risk of side effects and adverse events.
• EYE EXPOSURE- Protective eyewear (shields) will be provided to you during treatment. Failure to wear eye shields during the entire treatment may cause severe and permanent eye damage.

I acknowledge the following points have been discussed with me:
• Potential benefits of the proposed procedure, including the possibility that the procedure may not work for me.
• Alternative treatments such as sclerotherapy or surgery
• Reasonably anticipated heath consequences if this procedure is not performed
• Possible complications/risks involved with the proposed procedure and subsequent healing period

For women of childbearing age:
By signing below, I confirm that I am not pregnant and do not intend to become pregnant anytime during the course of treatment. Furthermore, I agree to keep the Dr. and staff informed should I become pregnant during the course of treatment.