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Consent-form Acne (1)

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COSMETIC DERMATOLOGY
NEHS
NORTH EASTERN HEALTH SPECIALISTS
nehs.com.au
CONSENT FORM
ACNE Treatment
I, _____________________________________DOB:__________________,
of____________________________________________________________
authorize ………………………………………………… of
North Eastern Health Specialist to
perform hair removal with the BBL / Nd-Yag laser on the following area(s) of my body
The Dermatologists at the North Eastern Health Specialists are trained in the use of BBL and class 4
medical lasers. A certificate in the Safety of Laser Use has been obtained by all members trained in
the use of this equipment at NEHS. These members include
Dr Shireen K Sidhu (Dermatologist)
Dr Hoang Ly (Dermatologist)
Mrs Sharon Habib (Registered Nurse)
Mrs Helen Marzola (Registered Nurse)
BBL (BroadBand Light) for the use in Acne Treatment utilizes light to destroy or minimize P. acnes
bacteria, reduce inflammation, and minimize over production of sebaceous oil glands. This therapy
may utilize multiple BBL filters (420 nm, 560 nm, 590 nm) to target selectively the P. acnes bacteria and
sebaceous oil glands. The goal is to pack the skin with light to impact the entire pilosebaceous unit.
CONSENT FORM
Review of facts about light therapy
BBL selected filters: 420 nm, 560 nm, 590 nm for the treatment of acne:
o The 420 nm filter (blue light) is effective in targeting porphryins. The porphryins are produced by the
Propionibacterium acnes bacteria (P. acnes). The blue light will cause photo excitation of these P.
acnes porphryins after exposure to the light. This process forms singlet oxygen within the
microorganism itself, leading to the selective destruction of the bacteria.
o The addition of the 560 nm filter (yellow light) is effective in treating mild to moderate inflammatory
acne lesions.
o The addition of the 590 nm filter (red light) is effective in treating the deeper lesion that is impacted by
the sebaceous oil gland. The red light is heating the gland to aid in minimizing its production of oil.
Multiple consecutive sessions will be needed to reduce acne and the severity of lesions. Treatment
schedule: ________ number of sessions per week for a minimum of ……..weeks are necessary as part
of the acne therapy program.
Pre- and post-care requirements and instructions must be followed.
Approximately, a 40-80% reduction in the number of lesions and the prevention of new lesion formation is
the expectation from the treatment course.
Light from a laser can be harmful to eyes and wearing special safety eyewear is necessary at all times
during the procedures.
Light from BBL is an intense burst of light and even though the special safety eyewear is in place, you will
sense light emanating from the treatment area.
The sensation of light may be uncomfortable in certain areas and feel like pin pricks or bursts of heat.
Usually the use of topical anesthetic is avoided in light-based acne procedures. The use of topical
anesthetics is at the discretion of the practitioner as there are known severe allergic reactions to
ingredients in topical anesthetics. Patient’s with known allergies to anesthetics will list them
here:_________________
Common side effects and risks
Erythema (redness) may occur in the area of treatment. This may last several hours. Edema
(swelling) around the hair follicles is called peri-follicular edema and is a sign that the hair follicle
has been affected. Urticaria (itching) or hive-like appearance is also associated with the thermal
light affecting the surrounding skin. These symptoms usually subside in a few hours. A cool
compress placed on the area provides comfort. The treated area should be cared for delicately
for at least 12 hours. Limited activity may be advised, as well as no hot tub, steam, sauna, or
shower use.
A blister can form up to 48 hours after treatment. An antibiotic cream or ointment can be used.
Other short term effects include bruising, superficial crusting, and discomfort.
Hyperpigmentation (browning) and hypopigmentation (lightening) have been noted. These
conditions usually resolve within 2-6 months. Permanent color change is a rare risk. Vigilant
care must be taken to avoid sun exposure (tanning beds included) before and after the
treatments to reduce the risk of color change. Sunscreen and / or sun block should be applied
when sun exposure is necessary. Avoid fake tans for at least 24 hours
CONSENT FORM
Infection is not usual after treatment; however herpes simplex virus infections around the mouth
can occur following treatments. This applies to both individuals with a past history of the virus or
individuals with no known history. Should any kind of infection occur, your clinician must be
notified to prescribe appropriate medical care.
Allergic reactions resulting from treatment are uncommon. Some persons may have a hive-like
appearance in the treated area as discussed above. Some persons have localized reactions to
cosmetics or topical preparations. Systemic reactions are rare.
Please tick the following boxes when you are satisfied that the information provided is
acknowledged by yourself. If you are uncertain, your Dermatologist is there to discuss this
further with you. Please understand that it is crucial you follow the pre and post instructions. In
general, BBL is safe with no/minimal complications experienced when conducted by
experienced medical and nursing staff. A test area will be performed to ensure that your skin
reactions are appropriate.
I understand that all standard safety precautions and all BBL specific guidelines will be
followed to ensure the utmost in safety during my treatments. This includes the use of
protective eyewear at all times while the equipment is in use.
I am aware of alternative methods of treatment for hair removal such as topical products, oral
treatments and other light-based or laser systems as discussed with my Dermatologist. I
have explored such alternatives to my satisfaction, and have made an independent decision
to proceed with BBL treatments.
My Fitzpatrick skin typing has been analyzed, and I understand that a higher Fitzpatrick
typing increases the potential risk of the treatment. Hormonal therapy and other medical
conditions may also affect my results. Hair removal with BBL is limited to skin types I-V as
complications of the procedure increase with greater skin types. The Nd-Yag laser will be
used for skin type VI to prevent the risks described.
Results are cumulative; therefore a series of treatments is necessary to achieve maximum
benefit. Actual results cannot be guaranteed.
I will avoid sun tanning, tanning booths and tanning creams for at least 3 weeks prior to and
after all BBL treatments to reduce the risks of uneven pigmentation.
I understand that Roaccutane (or other Retinoids taken orally) should not be used for 6
months prior to this procedure.
Retin-A (or similar products containing isotretinoin) should not be used 24 hours prior to
treatment to minimize irritation. These topical retinoids may be used again one week after
the procedure.
I understand that treatments cannot be done on skin areas with open sores or lesions. I
understand that tattoos and permanent makeup may be altered and that moles may be
lightened. We therefore do not treat disease within tattoos and all moles are covered up so
as to not be accidentally treated.
CONSENT FORM
I understand that recurrent viral infections such as herpes simplex (cold sores) or varicella
(shingles) may be activated and that NEHS needs to be informed if there is a history of this.
An oral antiviral treatment may be prescribed over the 3 days before, during and after
laser/BBL treatment in order to reduce the risk of this infection.
I will advice my dermatologist if I am on any anticoagulant (blood thinning) medication
(including aspirin) or if there is a history of excessive bleeding or bruising.
I will also inform my dermatologist if I have had a history of sun sensitivity or if I am using any
sun sensitizing medications. I agree to provide NEHS with an accurate personal medical and
drug history prior to treatment.
As laser lights may bounce of reflective objects, I understand that all reflective objects such
as jewellery and watches must be removed if near the treatment area.
I understand that the sensation generated by the light pulse is most commonly described as
a rubber band snapping against the skin, and most individuals are able to tolerate this
sensation for the short duration of the treatment. I understand that I may have a sunburn type
sensation in the treatment area for several hours afterwards and may also experience
temporary redness similar to sunburn. Some skin swelling (edema), bruising, blistering,
scabbing, infection and other skin changes may also occur especially following facial
treatments.
I understand that in most cases, all of these effects should resolve over the next several
hours to days following treatment. I understand that cold compresses are beneficial, and in
extreme cases a mild steroid cream or antibiotic may be necessary and will be prescribed by
your Dermatologist.
Scarring is extremely rare and usually occurs in those with a predisposition such as a history
of keloids or other excessive scarring, but acknowledge that scarring is possible with any
patient. I have been advised not to undergo BBL treatments if I have such a history and
under these circumstances acknowledge that NEHS cannot be responsible for the outcome
of my treatment.
I understand that hypo-pigmentation (decreased skin coloration) or hyperpigmentation
(increased skin coloration) is uncommon, but if it occurs to me, although rarely permanent,
may last several weeks to months. I understand that post treatment use of sunblock is
advised to minimize the risk, and that in some cases bleaching creams add additional
benefit. Your Dermatologist will guide you on whether this is necessary.
I acknowledge receipt of pre and post treatment instructions and that I fully understand that
failure to follow these may affect my treatment outcome and increase the likelihood or
severity of complications. I also agree to carefully follow these post treatment instructions to
reduce the likelihood or severity of any skin changes.
Although long term risks of BBL causing pigmentation is not fully known, these complications
are unlikely. Studies done have supported their safe use when used by trained individuals.
However NEHS cannot be held liable for any BBL risk not yet discovered or is commonly
known.
CONSENT FORM
I agree that this consent shall apply to all subsequent treatments of a similar nature.
I understand that although every reasonable effort will be made to achieve a desirable
outcome no guarantees are stated or implied.
I certify that I am a competent adult of at least 18 years of age (Minors under 18 years of age
require additional consent from a parent or legal guardian.)
Photography
I do____ or do not _____ consent to photographs and other audio-visual and graphic materials before,
during, and after the course of my therapy to be used for medical, marketing, and education purposes.
Although the photographs or accompanying material will not contain my name or any other identifying
information. I am aware that I may or may not be identified by the photos.
I have read and understand all information presented to me before signing this consent form. I have
been given an opportunity to have all of my questions answered to my satisfaction. I understand the
procedure and accept the risks. I agree to the terms of this agreement.
Patient’s Name (Printed): ___________________________________
Signature: _______________________________________________
Date: _______________
Name of Doctor/ Reg. Nurse ________________________________
Signature of Doctor/ Reg. Nurse ______________________________
Date: _______________
230 St Bernards Road, Hectorville, SA 5073
Phone: 0883369073 fax: 08 83364370
[email protected]
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