Consent & Disclosure for
“Mini” Non-Invasive
Extreme Makeover
Preliminary Remarks
The “Mini” Non-Invasive Extreme Makeover Program designed to introduce
you to some of the new technology available to improve the health and
appearance of the skin. It addresses most of the concerns that clients
express such as unwanted pigmentation (browns and reds), poor texture, fine
wrinkles and sagging. It is a series of 6 treatments performed over a 6-10
week period by Dr. Christian and our Aesthetician. However, It should be used
only as an adjunct to well planned skin care program consisting of twice daily
cleansing, some form of exfoliation, moisturizing and sun protection. We will
review your current program of skin care and work with you to make sure you
are using appropriate products for your skin type during the initial
consultation. It is important that your skin be healthy before we apply some of
the technology to be sure we get rapid healing and the best results. We may
determine that your skin needs a month or two of skin care prior to any of the
laser or light treatments. We promote primarily the SkinCeutical line of
products and these can be purchased from us at a 10% Discount or in a
special package we have designed. In addition there may be other products
which may reduce the appearance of unwanted pigment and wrinkles or which
may enhance the effects of the procedures we will perform. It makes no
sense to apply some of the high technology procedures we will be using and
not be committed to a daily program of skin care for maintenance and
prevention of further damage. Much can be done over time with a daily skin
care program especially in terms of moisturizing/hydrating and sun protection.
The procedures in the “Mini” Non-Invasive Extreme Makeover program are
designed to hasten the improvement of your skin health and appearance but
this occurs best when the skin is well hydrated and nourished. We cannot
proceed with the “Mini” Makeover without your commitment to a daily skin
care program. It should be understood that a single series of treatments is
unlikely to achieve the final desired results and that a second or third “Mini”
series will most likely be required. This program allows you to see the results
of a single series of treatments and then you can decide regarding further
treatments.
I understand the importance of a daily skin care regimen and I agree to utilize
products appropriate to my skin type as recommended by Dr. Christian. If I
cannot afford a basic program of skin care products I understand I cannot
participate in the “Mini” Non-Invasive Extreme Makeover. Skin Care Products
are not included in the cost of the program and in some cases you may need
additional products to enhance the results of your program or post treatment
care. The cost of these is not included in the program. The initial cost of a
supply of basic skin care products may be about $200-$400.
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I have seen Dr. Christian’s PowerPoint Presentation regarding the procedures
to be applied including the Diamond Microdermabrasion, “Pixel” Laser Skin
Resurfacing, Infrared Skin Tightening and Intense Pulsed Light.
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The Program, Summary (May vary with your needs)
Initial Consultation, Digital and UV Light Pictures and review of Your Skin Care
Product Program.
1 Diamond Microdermabrasion with Javani Procedure
1 Intense Pulsed Light Treatment of Face for Pigmentation
1 Diamond Microdermabrasion with Javani Procedure
1 “Pixel” Laser Skin Resurfacing of the Face to include
1 Infrared Skin Tightening Procedure.
1 Diamond Microdermabrasion with Javani Procedure
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Expected Results
You will learn the basics about skin care and preventive measures.
Direct Effect of a series of Diamond Microderms with Javani
Improvement in the smoothness and texture of the skin because of efficient
removal of the outer dead layer of skin followed by Javani Hydration.
Direct Effect of a series of “Pixel” Laser Skin Resurfacing
Marked improvement in the appearance of fine wrinkles around the eye and
mouth.
Marked improvement in the appearance of acne scaring and traumatic scaring.
Marked improvement in the smoothness and texture of the skin.
Increase over time of Collagen, Elastin and Thickness of Epidermis enhancing
the results of the immediate shedding and regrowth of the epidermal layer.
Direct Effect of a series of Intense Pulsed Light
Improvement in the appearance of brown spots and redness/flushing of face.
Direct Effect of a series of Harmony Infrared Skin Tightening
Gradual improvement will be seen in sagging of the jowls and the skin of the
neck after a series of treatments.
Direct Effect of a Long Term Skin Care Program
Over the long term there will continue to be some improvement in some of the
following areas with a program of daily skin care & not due to the “Pixel”
Laser, Intense Pulsed Light or Infrared Skin Tightening.
Reduction in the appearance of pigment, brown or dark lesions
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Reduction in redness, flushing, small vessels, Rosacea
The skin will be more even toned and smoother
Continued Reduction in the appearance of fine wrinkles
Reduction in the occurrence of breakouts and blemishes
Increased Collagen, Elastin, thickness of Epidermis
Unfortunately, there will be continued sun exposure and progression of the
aging process therefore followup procedures and Skin Care Products will be
required to sustain improvements of some lesions for the long term.
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The Program, Details
Pre Program Diamond Microdermabrasion and Javani
Most Clients will have a Diamond Microdermabrasion and Javani Procedure
prior to your formal consultation to give you some idea of how profoundly
even a single treatment using Medical Grade Techniques can improve the
texture and appearance of your skin. At this session Dr. Christian will explain
some of the basics of skin care and some pictures will be taken.
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Initial Consultation and Treatment
During this consultation, Dr. Christian will review your present Skin Care
program and determine your Fitzpatrick Skin Type. More pictures will be taken
and the face and body will be examined for “targets” for treatment. A list of
these “targets” and our objectives will be made and a preliminary plan for
treatment will be formulated. This plan may change depending on how your
skin responds as the program progresses. If we feel the skin needs some rest
for rejuvenation, we may delay some treatments until the skin is ready for
more care. During this period, consistent use of skin care products
is critical to allow the skin to renew and repair. If suspicious cancerous
lesions are discovered during this consultation, referral to Dermatologist will
be made for resolution prior to the treatments.
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Indications
Indications For Use of “Pixel” Laser resurfacing
A series of “Pixel” Laser procedures assists in the treatment of the following skin
conditions:
 Skin resurfacing for rough skin
 Treatment of wrinkles around eyes, mouth
 Some Pigmentation will respond
 Skin tags
 Scars including acne scars
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Indications For Use of Intense Pulsed Light
A series of IPL procedures assists in the treatment of the following skin
conditions:
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Vascular changes, including spider veins, broken capillaries and the redness
and flushing associated with Rosacea.
Pigmentation changes, including brown/black spots or freckles associated
with aging and sun damage.
Large pores will be reduced in size and appearance.
Improvement in acne and other inflammatory lesions are reduced
Some congenital vascular lesions such as hemagiomas
Reduction in the redness of old scars
Some improvement in fine wrinkles and skin laxity over the long term with
continued maintenance treatments several times per year.
Some resolution of Actinic Keratoses with use of Levulan.
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Indications For Use of Infrared Skin Tightening
A series of Infrared Skin Tightening procedures assists in the treatment of the
following skin conditions:
 Mild to Moderate Sagging and Laxity of the Neck
 Mild to Moderate Sagging and Laxity of the Cheeks and Jowls.
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Contraindications
Contraindications For Use of “Pixel” Laser Skin Resurfacing or Intense Pulsed
Light or Infrared Skin Tightening
These procedures should not be performed if any of the following apply:
 I am an uncontrolled diabetic and/or subject to poor healing
 History of Keloid Scar formation
 Pregnancy
 Active tanning in the sun or in Tanning Booths/Beds for 4 weeks prior to the
treatment.
 Fitzpatrick Skin Types V and VI. Dark Brown or Black skin
 Use of Accutane in the 6-9 months prior to the treatment
 Use of Retin A if irritation and redness is present
 Use of anticoagulants such as Coumadin or Heparin or large doses of daily
aspirin.
 Botox or Restylane in the prior 2 weeks in the area to be treated.
 Scleroderma
 Prior Radiation in the treatment area
 Open Sores, infection, wounds or uncontrolled Acne.
 Active herpes simplex (cold sores) or shingles.
 Use of Sun Sensitizing Medications
 Suspicion of cancerous lesions.
None of these apply ___Initials
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Mechanisms of Action
Mechanism of action of the “Pixel” Laser
The “Pixel” Laser Device produces a beam of highly concentrated light at a wave
length of 2960nm delivered in a pulse of varied duration and energies. This
wavelength is very highly absorbed by water, which is the primary target. Clients
with very hydrated skin (dermis and epidermis) will have a more pronounced result.
Once the water absorbs the light, it is converted to heat which in turn
damages/destroys/vaporizes the undesirable target tissue. A portion of the epidermis
will be damaged which then sheds over 5-7 days leaving a smoother texture and fine
wrinkles and scars are diminished. The “Pixel” laser will penetrate also into the
dermis and heat up water which then denatures collagen leading to the formation of
new or remodeled collagen which then over the long term smoothes and tightens the
skin. In this procedure the Laser Pulse is divided into either 49 or 81 smaller pulses
which only damages a fraction of the skin, leaving much normal skin to aid in the
healing process. The body’s natural healing process then occurs and the damaged
tissue will flake off over a period of 5-7 days. The settings on the device consist of the
duration of the pulse and the energy and are determined by your skin type and the
type of target lesions. Initially the settings are on the low side to test how your skin
will react to the pulse and at subsequent sessions the settings are increased or
adjusted to get maximum results with minimal side effects. A “Conservative”
Treatment would entail only a single pass. A “Moderate” Treatment would entail 2
passes in different directions and an “Aggressive” Treatment would entail 2-3 passes
with “stacking” of pulses in problem areas.
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Mechanism of action of Intense Pulsed Light
The IPL Device produces a broad beam of highly concentrated light delivered in a
pulse. This light is filtered to a wavelength that is selectively absorbed by target
tissues, (the lesions we want to treat) with hopefully minimal effect of the surrounding
skin. Once the target absorbs the light, it is converted to heat which in turn destroys
the undesirable target tissue. The body’s natural healing process then absorbs the
damaged tissue or the damaged tissue will flake off over a period of days to weeks.
The settings on the device consist of the duration of the pulse and the energy and are
determined by your skin type and the type of target lesions. Initially the settings are
on the low side to test how your skin will react to the pulse and at subsequent
sessions the settings are increased or adjusted to get maximum results with minimal
side effects.
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Mechanism of action of Infrared Skin Tightening
The Infrared device produces a broad beam of highly concentrated light in the
Infrared range delivered in a pulse. This light is filtered to a wavelength that is
selectively absorbed by water in the dermis producing heating of the water. Once the
water is heated, there is denaturing of the collagen with subsequent remodeling
which results in some tightening of the overlying skin. These changes occur over
time and the final result might not be apparent for 4-6 months after a treatment. This
is the time that is needed for collagen remodeling to occur. There will be no shedding
of skin with this procedure and it will be done just prior to the “Pixel” Laser
Procedure.
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Alternatives to “Pixel” Laser Skin Resurfacing, Intense Pulsed Light and
Infrared Skin Tightening
I understand that these procedures are used as an adjunct to a comprehensive
program of skin care and a prolonged course of these products may achieve some of
the desired skin changes I am seeking. I have explored these alternatives to my
satisfaction and have made an independent decision to proceed with this series of
treatments in the hope that the desired skin changes may be more rapid, effective and
more lasting.
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Limitations
I understand that some improvement is achieved in nearly everyone, but that my
results and/or complete resolution of the undesirable target lesions are not expected
to occur with a single series of treatments. Results are limited by many factors
including the equipment capability as well as my personal skin characteristics. My
Fitzpatrick Skin Typing has been analyzed and I understand that a higher Fitzpatrick
Typing increases the potential risk of the treatment. Currently, “Pixel” Laser Skin
Resurfacing and Intense Pulsed Light are limited to Fitzpatrick Skin Types I – IV.
Hormonal therapy and other medical conditions may affect my results. Results are
cumulative and a series of treatments as well as a well planned program of skin care
products are necessary to achieve maximum benefit. Actual results cannot be
guaranteed.
My Fitzpatrick Skin Type is _____.
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Side Effects and Complications
Procedural Discomfort
“Pixel” Laser Skin Resurfacing
Pain and discomfort during the actual procedure of “Pixel” Resurfacing is minimal
and many comment only that they feel a slight snap or electrical tingle with each
Laser Pulse. At the end of the procedure the skin will start to feel slightly like a sun
burn. At this time cold wash cloths and air will be blown on the face which relieves
this to some extent. We will place some Javani Gel and other Hydrators such as B-5
Hydration Gel Prior to your departure. We may also use a light coat of a 1%
Hydrocortisone Cream.
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Intense Pulsed Light
Pain and discomfort during the procedure are the most common described side
effects. The pain is similar to a rubber band snapping against the skin and most
individuals are able to tolerate this sensation for the short duration of the treatment.
Dr. Christian may apply a topical anesthetic prior to the procedure in some
individuals. I cannot have a topical anesthetic if I have a known allergy to “caine”
type anesthetics such as benzocain, tetracain, xylocaine or lidocaine. Serious skin
reactions and rarely death due to a severe allergy can occur
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Infrared Skin Tightening
During this procedure the Infrared Device is gently brushed across a small area of
skin. After about 30 seconds the client will begin to feel some discomfort as the skin
heats up. We will ask you to gauge your pain on a scale of 1-5 with 5 being very
painful and not tolerable. When the skin gets to a 4 or 4.5 level, the client will indicate
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by saying “Now” and Dr. Christian will remove the device for a few seconds and
allow the skin to cool down and then start the process again. We want to heat up the
skin to about a 4 level and keep it there for about 30 seconds.
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Burning, Blistering, Scarring, Swelling and Infection
The “Pixel” Laser, Intense Pulsed Light and Infrared Skin Tightening work by creating
heat to damage the target lesion and hopefully leave the normal tissues undamaged.
Sometimes the target lesions take up enough light and covert it to heat that swelling
or burning and then a blister will form. For this reason, the initial treatment may be
on the Conservative side to evaluate how your skin will respond. If Dr. Christian
senses that my skin has been recently tanned, he has the option of canceling a
scheduled procedure for 3 weeks until the tan has subsided. Please realize that a
sunburn type sensation with a little swelling is normally seen for up to 2 days after
these treatments especially in aggressively treated areas and around the eyes. This
can be relieved to some extent with a 1% Hydrocortisone Steroid Cream and
Lanacaine Topical Cream, both available over the counter. If blistering develops, I
will contact Dr. Christian and he will prescribe a treatment program to allow for
healing of the blister which may include antibiotics especially if there is a suspicion
of infection or that the infection has spread to the blood (Very Rare). If untreated the
blister may become infected with poor healing or pigment changes. Scarring is rare
but can occur in individuals with a history of Keloid formation or if a secondary
infection occurs. In some patients there can be activation of herpes simplex (cold
sores) or herpes zoster (Shingles) in and around treated areas and I may need
antiviral treatment to hasten resolution.
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Bruising and Bleeding
The “Pixel” Laser and Intense Pulsed Light can potentially can damage tiny blood
vessels in the upper dermis. This might lead to the appearance of some bruising in
the treated areas. Blood vessels however are not the target for the “Pixel” Laser but
the Intense Pulsed Light is helpful for small red and blue spider like vessels of the
cheek, nose and chin. A small bruise on the face will resolve in 7-10 days but on the
body may take 2-4 weeks or longer to resolve.
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Pigment Changes
If a blister forms or some bruising occurs, the healing process may result in either
some increased pigmentation or decreased pigmentation. This may last several
months and slowly improve or may be permanent. The use of post treatment
sunscreen can minimize this risk and in some cases bleaching creams may be of
additional benefit.
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Blindness or Eye Damage
The “Pixel” Laser, without protective eyewear, may cause visual loss including
blindness. It is important to keep eye shields on at all times during the procedure and
I should keep my eyes closed in order to protect my eyes from accidental exposure.
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Diamond Microdermabrasion or Facials with Javani
We will perform 3 Diamond Microdermabrasions with the Javani Procedure in
conjunction with these procedures to help hasten the removal of the damaged
epidermal layer and pigmented lesions which are shedding. The side effects of
these procedures consist only of some mild redness and a slight sunburned
or wind burned feeling for about 12-24 hours after the procedure. Rarely some
bruising or serious irritation may occur.
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Operator
Your procedure for the “Pixel” Laser, Intense Pulsed Light and the Infrared
Skin Tightening will be provided by Dr. Christian who has been trained in laser
science, use of the equipment, laser safety and skin care.
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Safety
All standard safety precautions will be followed to ensure the utmost safety
during your treatments. This includes the use of protective eyewear at all
times while the equipment is in use. We recommend removal of contact
lenses during facial treatments.
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Long Term Risk
I understand that the long term risks of the “Pixel” Laser for Skin Resurfacing,
Intense Pulsed Light and Infrared Skin Tightening may not be fully known.
Although considered safe and research studies have shown these types of
treatment to be useful for the Indicated conditions, Inside Outside Wellness
Center and Medical Spa cannot be held responsible for any “Pixel” Laser Skin
Resurfacing, Intense Pulsed Light or Infrared Skin Tightening risk not yet
discovered or commonly known.
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Continued Consent
I agree that this consent shall apply to all subsequent treatments of a similar
nature.
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Guarantee
I understand that although every reasonable effort will be made to achieve a
desirable outcome no guarantees are stated or implied. If you incur a
complication which prohibits further treatments we will refund your money.
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Photographs
I consent to the taking of photographs prior to and during the period of
treatment to document the changes and any complications that might occur.
These photographs will be the property of Dr. Christian and may be used for
teaching and demonstration purposes and my identity will not be revealed at
any time.
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Physician Option to Modify or Discontinue Program
Dr. Christian reserves the option to modify the program at any time to achieve
the best results with the technology we have available. In addition, Dr.
Christian reserves the option to discontinue the program at any time he feels
the patient is not complying with the directed skin care program or is having
other procedures done at another facility which may jeopardize this program.
I agree to inform Dr. Christian of new medicines or any new procedures I am
having performed on my skin.
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Post Procedure Considerations: Important Information
Sun Exposure: I realize that exposing the treated area to the sun during the
period of treatment will potentially reverse some of the beneficial changes we
have achieved and may increase the risk of complications. Immediately after
the procedure and for a few days the skin will have a mild to moderate sun
burn feeling. Sun Exposure during this period would make it worse and
should be avoided. I will not intentionally tan the treated areas and I will
always use the recommended sun protection (SkinCeutical Daily Sun Defense
SPF 20) if I go out in the sun, even on overcast and rainy days. UVA radiation
will penetrate clouds and windows so protection is needed at all times.
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Care of Treated Skin Post Procedure:
1. The “Pixel” appearance of the treated skin will be visible until the layer of
dead epidermal skin sheds off and pigmented lesions will be slightly darker.
On about the 3rd day the dead epidermal layer will feel a little “leather” like and
then start to slowly shed. Pigmented lesions should flake off by the 7th day.
2. I will clean my skin twice daily with a gentle cleanser and not attempt to
pick at or peel off the dead epidermal layer or the pigmented lesions which are
shedding. I will let this layer of dead skin and the pigmented lesions come off
naturally. I realize that removing this shedding layer or the flaking pigmented
lesions prematurely may lead to an underpigmented area which may be much
different from the surrounding skin, especially if my skin has some natural
pigment in it.
3. The ‘Pixel” appearance may be concealed to some extent with make up or
foundation but in some cases it actually makes the “Pixel” appearance more
exaggerated. Simply keeping the skin hydrated with Javani Cream, B-5
Hydrating gel or applying the 1% Hydrocortisone Cream will tend to minimize
the “Pixel” appearance.
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Blistering: If a blister develops, I will notify Dr. Christian for instructions on
how to care for it.
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Followup Visits: I understand Dr. Christian may ask me to return for a short
visit 1-3 days after my procedures to check on my skin and the results of the
procedure. These visits are important as they give Dr. Christian a better idea
of the settings to use at my next session. If Dr. Christian asks me to return for
a short followup visit I will do so and not make him chase me down.
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I certify that I am a competent adult of at least 18 years of age.
Minors (under 18 years of age) require additional consent form a parent or
legal guardian.
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Importance of On Time Appointments
I will do my best to be on time for the appointments. There is much to do in
the hour allotted for the treatments. I realize that it is not safe to have Dr.
Christian rushed through a “Pixel” Laser treatment. If you are over 15 minutes
late we may decide to reschedule the procedure.
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My signature attests to the fact that I have fully read this entire Consent and
Disclosure form, that I have had any concerns answered to my satisfaction,
that I understand the information contained within, and accept the risks
inherent in “Pixel” Laser Skin Resurfacing and/or Infrared Skin Tightening
Treatments.
I hereby consent to proceed with the ‘Mini” Non-Invasive Extreme Makeover
consisting of 3 Diamond Microdermabrasions with Javani Procedure, “Pixel”
Laser Skin Resurfacing, Intense Pulsed Light and Infrared Skin Tightening
Treatments.
In understand the areas to be treated are the Face for the Intense Pulsed Light,
‘Pixel” Laser and Diamond Microdermabrasions. The Neck, Cheek and Jowls
will be treated with Infrared Skin Tightening.
If I desire other areas to be treated there will be an additional charge.
Please Initial other Area(s) to be treated.
Neck “IPL”: _________
Neck “Pixel”: __________
Hands “IPL”: _________
Hands “Pixel”: __________
Chest “IPL”: _________
Chest “Pixel”: ________
Other, Identify: _______________________
Date: _______________
Signed: ___________________________
Printed Name: _________________________
Parent/Legal Guardian for Patient under 18: _____________________________
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