Consent & Disclosure for
Non-Invasive
“Extreme Makeover” Program
Preliminary Remarks
The Non-Invasive “Extreme Makeover” Program is a series of 16 treatments
performed approximately once a week by Dr. Christian and the Aesthetician to
markedly increase the health and appearance of your skin. 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. We promote primarily the SkinCeutical line of
products and these can be purchased from us at a 10% Discount. In addition
there may some 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 but the procedures in the
“Extreme Makeover” program are designed to hasten the improvement of your
skin health and appearance. We cannot proceed with the “Extreme Makeover
without your commitment to a daily skin care program.
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 program of skin care products I understand I cannot
participate in the “Extreme Makeover” program. 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. The cost of these
is not included in the program. The initial cost of a supply of basic skin care
products may be about $300.
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The Program, Summary
Complementary Diamond Microdermabrasion and Javani
Initial Consultation and Your Skin Care Product Program
6 Intense Pulsed Light (IPL) Treatments of Face, Neck, Hands with Javani
3 Nd:Yag Laser treatments of Spider Veins or other lesions for 30min each
7 Diamond Microdermabrasions or Facials with Javani
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Expected Results
You will learn the basics about skin care and preventive measures
Markedly reduce the appearance of pigment, brown or dark lesions
Markedly reduce redness, flushing, small vessels, Rosacea
The skin will be more even toned and smoother
Markedly reduce the appearance of fine wrinkles
Markedly reduce the occurrence of breakouts and blemishes
Increase Collagen, Elastin, thickness of Epidermis
Over the long term there may continue to be some improvement in some of
these areas especially with a program of daily skin care.
Alternatively, there will be continued sun exposure and the aging process
continues and a maintence program of IPL and Microdermabrasions most
likely be required.
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The Program, Details
Complementary Diamond Microdermabrasion and Javani
You may receive a complimentary treatment consisting of a Diamond
Microdermabrasion and Javani Procedure prior to your formal consultation to
give you some idea of how profoundly even a single treatment 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 one hour 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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6 Intense Pulsed Light (IPL) Treatments with Javani
Intense Pulsed Light (IPL) is a very useful tool to reduce the appearance of
skin changes associated with aging and sun damage. Any IPL treatment
program will consist of a series of 5-6 treatments, with a minimum of 2 weeks
between treatments. Other procedures such as Diamond Microdermabrasion
and Chemical Peels/Facials will be used between some of the sessions to
enhance the effects of the device as well as your daily skin care program.
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Indications For Use of IPL
A series of IPL procedures assists in the treatment of the following skin conditions:
 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 hemangiomas
 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 (pre Cancerous Lesions) with use of
Levulan.
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Contraindications For Use of IPL
IPL should not be used if any of the followed apply:
 I am diabetic and subject to poor healing
 History of Keloid Scar formation
 Pregnancy
 Active tanning in the sun or in Tanning Booths for 4 weeks prior to the
treatment.
 Fitzpatrick Skin Types V and VI. Dark Brown or Black skin
 Use of Accutane in the 6 months prior to the treatment
 Use of Retin A in the week prior to the treatment
 Use of anticoagulants such as Coumadin or Heparin and large doses of daily
aspirin.
 Open Sores or 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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Mechanism
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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Operator
Your procedure 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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Alternatives to IPL
I understand that IPL is 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 IPL 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 rejuvenation is achieved in nearly everyone, but that my
results and/or complete rejuvenation and resolution of the undesirable target lesions
may not occur. 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, IPL Photo Rejuvenation is limited to 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.
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Side Effects and Complications
Discomfort
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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Burning, Blistering, Scarring and Swelling
The IPL device works by creating heat to destroy 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. Tanned skin
and especially recent tanning will increase the possibility of damage to the normal
skin. Tattoos or permanent makeup will take up the light readily and can easily blister
and we will stay away or cover these areas. Please realize that a sunburn type
sensation with a little swelling is normally seen for up to a day after the treatment.
This can be relieved to some extent with aloe Vera products or a mild steroid cream.
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. If untreated
the blister may become infected with poor healing. Scarring is rare but can occur in
individuals with a history of Keloid formation. In some patients there can be
activation of herpes simplex (cold sores) in and around treated areas.
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Bruising and Bleeding
When the target tissues are blood vessels, the heat generated hopefully will cause
them to go into spasm and the blood will clot and the body will then slowly absorb
the blood vessel through a normal healing process. Occasionally, the blood vessel
will rupture cause a small bruise which on the face will resolve in 7-10 days but on the
body may take 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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Long Term Risk
I understand that the long term risks of IPL use may not be fully known. Although
considered safe and research studies have shown IPL to be useful for the Indicated
conditions, Inside Outside Wellness Center and Medical Spa cannot be held
responsible for any IPL risk not yet discovered or commonly known.
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3 Nd:Yag Laser Treatments of 30min duration.
The 1064 Nd:Yag laser is a very useful tool to reduce the appearance of spider
veins, some congenital vascular lesions and some skin tags. Much can be
achieved with 3 treatments of some lesions and some will be treated with only
a single treatment. If more than 3 treatments are required for some areas,
there will be a 50% reduction in the cost of these treatments. I understand that
all of the proceeding comments in the IPL section also apply to the Nd:Yag
Laser. This is especially true of the side effects and complications. These
procedures will not be followed with Javani Treatments.
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7 Diamond Microdermabrasion or Facials with Javani
Interspersed between the IPL and Nd:Yag Laser treatments we will perform 7
other procedures consisting of Diamond Microdermabrasions and/or facials
with the Javani Procedure. The side effects of these procedures consist only
of some mild redness and a slight sunburned or windburned feeling for about
12-24 hours after the procedure. Rarely some bruising or worse irritation may
occur.
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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 not guarantees are stated or implied, however, if you are
not completely satisfied with the improvements in the health and appearance
of your skin or the treatment you received, we will refund your money.
Alternatively, if you wish to stop the program, we will make a partial pro rated
refund.
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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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Physican 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 client is not complying the directed skin care program or is having other
procedures done at another facility which may jepordize 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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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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My signature attests to the fact that I have fully read this entire consent form,
that I have had any concerns answered to my satisfaction, that I understand
the information contained within, and accept the risks inherent in IPL and
Nd:Yag laser treatments.
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I hereby consent to proceed with the Inside Outside “Extreme Makeover”
Program.
Date: _______________
Signed: ___________________________
Printed Name: _________________________
Parent/Legal Guardian: ______________________________
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