I authorize the practitioners of Dermani Medspa to perform Pharmaceutical Grade Facial Peels, Facials, Dermaplaning, Micro-needling, Microdermabrasion, Injectables, Radio Frequency, Laser Hair Removal and/or IPL treatments on me in an effort to improve/treat the following: Exfoliate or Remove outer layers of skin, Hair Reduction / Pseudofolliculitis Barbae /Dyschromia / Hyperpigmentation / Hair Reduction / PWS / Haemangioma / Angioma / Rosacea / Telangiectasia / Leg veins /Skin tightening/ Body Contouring/ Skin Rejuvenation.
I understand that there is a rare possibility of side effects or serious complications including permanent discoloration and scarring. I am aware that careful adherence to all advised instructions will help reduce this possibility.
I understand the below list of short-term effects and agree to follow matching guidelines:
Your Participation - in your skin care treatments will determine the outcome. It is important that you strictly adhere to your home care that your Nurse/esthetician has recommended.
No guarantee - Is expressed or implied as to the precise results or discomfort.
Discomfort – Discomfort Lasers/Radio Frequency: during the procedure and shortly after, I might experience an itching sensation or rubber band snap which degree will vary per hair density, area sensitivity and treatment head used but that does not last long. A mild “sun-burn” sensation may follow for typically up to one hour and will be reduced with application of cooling and soothing creams.
Discomfort Facial Treatments: During the treatment you may experience some temporary stinging or warm flushing. This will fade within a few minutes. During the next few hours, you may experience some tightening of the skin, which may last for several days.
For Facial Peels - For most patients, flaking begins within 48 hours. It is impossible to pre-determine how much peeling will occur. The shedding process usually subsides within 5-7 days. Depending on the clinical peel performed and your skin quality, the following reactions may occur in some patients: 1) Prolonged redness, irritation & flakiness, 2) Dryness and sensitivity, 3) Severe allergic reactions in rare instances.
For Laser Treatments/Radio Frequency:
Perifollicular erythema/oedema – severity and duration of the rash depend on the intensity of the treatment and the sensitivity of the area to be treated. These phenomena may be reduced with application of cooling and/or inflammatory creams.
Micro-crusting over some areas with very dense and coarse hair – may take 5 to 10 days to flake off and it is important not to manipulate or pick which may otherwise lead to scarring.
Bruising may rarely occur and may last several days.
Flaking of pigmented lesions – crusts may take 5 to 10 days to disappear and it is important not to manipulate or pick which may otherwise lead to scarring.
Reddening and swelling – severity and duration depend on the intensity of the treatment and the sensitivity of the area to be treated. These phenomena may be reduced with application of cooling and/or inflammatory creams.
I understand that sun exposure or tanning of any sort is not aligned with the pre and/or post-care instructions and may increase the chance for complications.
I am familiar with the procedure as well as potential benefits and/or risks have been thoroughly explained to me and I have had all my related questions answered.
Pre and post-care instructions have been discussed and are completely clear to me and/or I am familiar with pre and post-care instructions.
I understand that results may vary with each individual and acknowledge that it is impossible to predict how I will respond to the treatment and how many sessions will be required.
I consent to photographs being taken for the purpose of documenting my progress and response to the treatment and be kept solely in my medical record.
I agree to review Dermani Medspa's facial treatment, Injectables, Radio Frequency and laser pre-treatment compliance checklist along with my Physician and bring accurate and updated data, to the best of my knowledge. I agree to inform the treating practitioners at Dermani Medspa of any changes in any medications or supplements I am taking each visit.
I acknowledge that it is my right to view the HIPAA Notice of Privacy Practices (the "Notice") from Dermani Medspa revised 10-7-2014 available by asking the front office coordinator. I understand that I have certain rights to privacy regarding my protected health information. Dermani Medspa can and will use my protected health information for purposes of my treatment and to obtain payment for the services I receive from Dermani Medspa. The Notice explains in more detail how Dermani Medspa may use and share my protected health information for other purposes. I have the rights regarding my protected health information listed in the Notice. Dermani Medspa has the right to change the Notice from time to time and I can obtain a current copy of the Notice by contacting the person listed in the Notice. In the event I need to be contacted by the Medical Director of Dermani Medspa, I hereby authorize the Medical Director to contact me using his/her personal cell phone.
I hereby give my consent and authorization voluntarily and release Dermani Medspa from any claims, implied or stated that I have or may have in the future with this treatment, regardless of result. I am stating that the treatment and precautions above have been explained to me in detail and that I fully understand.
If client is a minor, I certify that I am the legal guardian of the client to be treated, that I am at least 18 years old and that I agree to all of the above for this minor.
My signature certifies that I have duly read and understand the content of this informed consent form. I hereby freely consent to Facial and or Body Treatments, and/or Injectables, and/or Radio Frequency and/or Laser treatments.