Patient Consent Form For Laser Genesis Skin Therapy Treating Warts (Page 2 of 4) in pdf

PATIENT CONSENT FORM

FOR LASER GENESIS SKIN THERAPY TREATING WARTS

I hereby authorize Look Young Atlanta or any delegated associates to perform Laser Genesis Non-Ablative

Skin Therapy on me for the treatment of warts. I understand that this procedure works by targeting the chromophore in the vascular

component of the wart. I understand that multiple treatments are required and it is possible the result will be minimal or not help at

all.

I am aware of the following possible experiences/risks:

• DISCOMFORT – A slight warming sensation may be experienced during treatment.

• REDNESS/SWELLING/BRUISING – Short term redness (erythema) or swelling (edema) of the treated area is common and may

occur. There also may be some bruising.

• PIGMENT CHANGES (Skin Color) – During the healing process, there is a possibility that the treated area can 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.

• WOUNDS – Treatment can result in burning, blistering, or bleeding of the treated areas. If any of these occur, please call our

ofﬁce.

• INFECTION – Infection is a possibility whenever the skin surface is disrupted, although proper wound care should prevent this. If

signs of infection develop, such as pain, heat, or surrounding redness, please call our ofﬁce at 404 239 3911.

• SCARRING – Scarring is a rare occurrence, but it is a possibility if the skin surface is disrupted. To minimize the changes of

scarring, it is IMPORTANT that you follow all post-treatment instructions carefully.

• EYE EXPOSURE – Protective eyewear (shields) will be provided. It is important to keep these shields on at all times during the

treatment in order to protect your eyes from injury.

The following points have been discussed with me:

• Potential beneﬁts of the proposed procedure

• Possible alternative procedures such as topicals, microdermabrasion, or surgery

• Probability of success

• Most likely possible complications/risks involved with the proposed procedure and subsequent healing

period

For women of childbearing age: By signing below I indicate that I am not pregnant. Futhermore, I agree to

keep Look Young Atlanta and staff informed should I become pregnant during the course of treatment.

Photographic documentation will be taken. I hereby do___do not___authorize the use of my photographs for

teaching purposes.

Arbitration and Dispute Settlement. Except for claims for injunctive or equitable relief, any dispute arising under this Agreement

shall be ﬁnally settled in accordance with the Comprehensive Arbitration Rules of the Judicial Arbitration and Mediation Service, Inc.

(“JAMS”) by an arbitrator appointed in accordance with such Rules. The arbitration shall take place in Atlanta, Georgia, in the

English language, and the arbitral decision may be enforced in any court. The award rendered by the arbiter to the prevailing party

in any action or proceeding to enforce this Agreement shall include costs of arbitration, reasonable attorneys! fees and reasonable

costs for expert and other witnesses, and any judgment on the award rendered by the arbitrator may be entered in any court of

competent jurisdiction."

ALL CLAIMS MUST BE BROUGHT IN THE PARTIES! INDIVIDUAL CAPACITY, AND NOT AS A PLAINTIFF OR CLASS MEMBER

IN ANY PURPORTED CLASS OR REPRESENTATIVE PROCEEDING, AND THE ARBITRATOR MAY NOT CONSOLIDATE MORE

THAN ONE PERSON!S CLAIMS. YOU AGREE THAT, BY ENTERING INTO THESE TERMS, YOU AND LOOK YOUNG ATLANTA,

LLC ARE EACH WAIVING THE RIGHT TO A TRIAL BY JURY OR TO PARTICIPATE IN A CLASS ACTION.

ACKNOWLEDGMENT

By my signature below, I certify that I have read and fully understand the contents of this permission form for Laser Genesis

treatment, and that the disclosures referred to herein were made to me.

931 monroe drive | suite 102-494 | atlanta, georgia 30308 | 404-239-3911

______________________________________________#

____________________________

Signature##

Date

Patient Consent Form For Laser Genesis Skin Therapy Treating Warts Page 2

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