GentleMAX Laser Treatment Consent Form
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(This form is courtesy of John W. Shore, M.D., a practicing ophthalmologist in Austin, Texas.)
Informed Consent for GentleMAX 755/1064 Laser Treatment of Vascular and Pigmented Lesions
WHAT ARE THE INDICATIONS FOR THE GENTLEMAX LASER?
The GentleMAX Laser is a device that produces an intense but gentle burst of light that treats the abnormal vascular and pigmented blemishes (including freckles, age spots, spider veins) without permanently affecting the surrounding skin.
WHAT ARE THE POTENTIAL BENEFTS OF TREATMENT?
Lesions usually fade slowly over time as the treated vessels or areas of pigmentation are eliminated by normal post-treatment healing. Immediately following treatment the areas treated are surrounded by a red flush. This reaction is normal and should resolve over 2 hours to 2 days after treatment. Most vessels will disappear during the treatment. Some larger vessels may only be reduced in size and require a second treatment. Pigmented spots will turn darker during treatment and will remain visible until the superficial crust, which forms only over the treated spots, falls off naturally 7 to 14 days after the treatment. After the crust falls off the treated areas may look slightly pink for a short time. Gradually a normal skin color returns.
WHAT ARE SOME OF THE POTENTIAL SIDE EFFECTS OF TREATMENT?
Areas treated for abnormal vessels may also form a linear scaly surface crust over the vessels treated. These will fall off after a few days. Discomfort is minimal and can be treated with an application of cool compresses or topical antibacterial ointment following the procedure.
WHAT ARE SOME OF THE TREATMENT ALTERNATIVES?
There are various other treatment options available for the treatment of vascular and pigmented lesions including topical creams and ointments, surgery, or freezing. You can also choose to accept the appearance of these areas and not change them.
WHAT ARE THE RISKS/COMPLICATIONS OF USING THE GENTLEMAX LASER?
Some possible complications of GentleMAX laser treatments include but are not limited to:
Wound Healing: The GentleMAX laser causes a disruption to the skin that takes several days to heal. The superficial injury of the outer layers of skin may result in swelling or crusting over the treated area. After the surface has healed, it may become sensitive to the sun for another two to twelve weeks.
Pigment Changes: The treated area may heal with increased or decreased pigmentation (coloring). This occurs most often in darker pigmented skin and following exposure of the area to the sun. It is recommended to protect the treated area from any sun exposure with an SPF of 30+ for 3 – 4 weeks following treatment. If increased pigmentation occurs, it usually fades in three to six months; however, pigment changes can be permanent.
Scarring: There is a small chance of scarring including hypertrophic scars or very rarely, keloid scars. Keloid scars are raised scar formations. To minimize chances of scarring, it is important that you follow all postoperative instructions carefully. It is important to tell your doctor about any prior history of unfavorable healing.
Lesion Recurrence: Some vascular and pigmented lesions may not go away completely or may recur after treatment despite the best efforts made.
Complete clearing of lesions may not be possible and will depend upon the type, age and color of the lesion. Multiple treatments may be needed for the best results. If additional laser treatments are necessary, subsequent treatments will normally follow at four to six week intervals.
There is no guarantee as to the result that will be obtained by these procedures.
PATIENT’S ACCEPTANCE OF RISKS
By providing your signature below, you acknowledge that you have read or have had read to you the contents of this form. Further, your signature indicates that you understand the information presented above and feel that you have been adequately informed of alternative treatment options and potential risks of the proposed laser treatment.
Please initial: _____ I am not currently using Accutane (acne treatment) nor have I used Accutane in the past 12 months. Please initial: _______I am not pregnant (female clients).
I have read and understood all information presented to me before signing this consent form.
Signed: ________________________________________________Date:________________
Provider: _______________________________________________Date:________________
Dacryocystorhinostomy (DCR) Consent Form
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INFORMED CONSENT FOR DACRYOCYSTORHINOSTOMY (DCR)
(“Tear drain bypass surgery”)
WHAT CAUSES THE NEED FOR DCR SURGERY?
Because of age, injury, or chronic sinus disease, the bony tunnel that drains tears from the eye into the nose can become blocked. Tears may then back up and run down the cheeks and, in some cases, an infection can develop underneath the skin between the eye and the nose (“dacryocystitis”). Many patients complain also of a gooey discharge and eye irritation.
HOW IS DCR SURGERY PERFORMED?
In a dacryocystorhinostomy (DCR), an incision is made near the inside corner of the eye or within the nose and a new opening is made to allow tears to drain from the eye into the nose. A flexible stent tube may be left in place for a few weeks (sometimes longer) to keep the new drain open. This tube can be removed in the office. The goal of surgery is to eliminate tearing, discharge, and irritation, and reduce the risk of infection.
HOW WILL DCR SURGERY AFFECT MY VISION OR APPEARANCE?
A DCR will not directly affect your vision though many people see better after surgery because they no longer have tearing or discharge from the eye. If an incision has been made on your skin, a small scar will be created.
WHAT ARE THE MAJOR RISKS OF DCR SURGERY?
Risks of DCR include but are not limited to bleeding, infection, and scarring. In addition, the new drainage channel may not stay open; this happens in less than 10% of all cases, and may require additional surgery to correct. There are additional costs if the surgery needs to be repeated or if revisions are required.
WHAT ARE THE ALTERNATIVES?
You may decide to live with the tearing, discharge, and irritation that a blocked tear duct can cause. However, if you have had an infection, your surgeon will likely advise surgery to prevent future infections, since these can, in rare circumstances, lead to vision loss. If your tear duct is completely blocked, there is no other surgery, injection, or medicine available to treat this condition. If your tear duct is partially blocked, a balloon can be inflated and/or tubes placed to enlarge the duct and keep it open.
WHAT TYPE OF ANESTHESIA IS USED? WHAT ARE ITS MAJOR RISKS?
DCRs can be performed under sedation with local anesthesia (injections around the nose and eye), or under general anesthesia. Risks of anesthesia include but are not limited to damage to the eye and surrounding tissues and structures, loss of vision, breathing problems, and, in extremely rare circumstances, stroke or death.
PATIENT’S ACCEPTANCE OF RISKS
I have read the above information and have discussed it with my physician. I understand that it is impossible for the physician to inform me of every possible complication that may occur. My physician has told me that results cannot be guaranteed and that adjustments and more surgery may be necessary, which can result in additional costs. By signing below, I agree that my physician has answered all of my questions and that I understand and accept the risks, benefits, and alternatives of DCR surgery, and understand the costs involved.
I consent to DCR surgery on:
________ Right eye _________ Left eye _________ Both eyes
_____________________________________ ____________
Patient (or person authorized to sign for patient) Date
CO2 Laser Skin Resurfacing Consent Form
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NOTE: THIS FORM IS INTENDED AS A SAMPLE FORM. IT CONTAINS THE INFORMATION OMIC RECOMMENDS YOU AS THE SURGEON PERSONALLY DISCUSS WITH THE PATIENT. PLEASE REVIEW IT AND MODIFY TO FIT YOUR ACTUAL PRACTICE. GIVE THE PATIENT A COPY AND SEND THIS FORM TO THE HOSPITAL OR SURGERY CENTER AS VERIFICATION THAT YOU HAVE OBTAINED INFORMED CONSENT.
Version 12/1/2002
INFORMED CONSENT FOR CO2 LASER SKIN RESURFACING
I DECLARE THAT I UNDERSTAND THE FOLLOWING INFORMATION:
The goal of CO2 laser skin resurfacing surgery is to reduce or partially eliminate facial wrinkles or reduce scarring from skin conditions such as acne. Generally, the results of CO2 laser skin resurfacing demonstrate improvement in the smoothness of the skin; however, a complete elimination of wrinkles or scarring is not a realistic expectation.
Alternatives to CO2 Laser Skin Resurfacing:
The alternatives to CO2 laser skin resurfacing surgery include dermabrasion and chemabrasion. The advantages and disadvantages (risks and benefits) of each of these alternatives to CO2 laser skin resurfacing surgery have been explained to me as well as the alternative of having no surgery, accepting my present skin condition, using cosmetics and considering other methods of skin rejuvenation surgery.
Possible Intra-operative Complications of CO2 Laser Skin Resurfacing Surgery:
Blindness/Corneal Burns – There is a risk of accidental eye injury by the laser energy or beam, which could cause blindness or burns of the eyeball. This is unlikely since complete eye protection is provided at all times during the laser energy applications.
Please initial after reading this page_________
Flash Fires – Utilization of laser energy always raises the possibility of fire-related incidents. These are rare and are preventable by careful maintenance of the surgical equipment and stringent laser safety precautions.
Possible Short-term Effects of CO2 Laser Skin Resurfacing Surgery:
Pain – Discomfort, burning sensation or pain the first few days after surgery. A local anesthetic is usually used to block pain during the treatment, but some degree of discomfort will occur after the anesthetic effects have worn off and this pain may persist for several days.
Redness of Skin – Erythema or redness of the skin for a two- to six-month period or possibly longer.
Swelling – Temporary edema (swelling) or ecchymosis (bruising) of the tissue of the face and neck, usually subsiding in three to seven days.
Wound Healing – Oozing, weeping, crusting and flakiness of the treated area, usually persisting for one to four weeks.
Skin Thickening – Textural changes of the treated skin, such as skin thickening, which may persist for a variable time following the laser skin resurfacing treatment.
Cysts – Milia or cysts, especially in the eyelid skin region (if the eyelid skin is included in the area of treatment by the laser energy), particularly if ointments were used in the postoperative phase for a protracted period.
Skin Tightness – Sensation of skin tightness (peaks at 3-8 weeks postoperatively).
Contact Dermatitis – Contact dermatitis due secondarily to topical preparations (ointments) used post- operatively.
Herpes Simplex Dermatitis (Fever Blisters) – Occurrence or recurrence of herpes simplex dermatitis, particularly if not pre-, intra- and post-operatively treated with a systemic antiviral medication such as Zovirax.
Skin Itchiness – Pruritis or itching in the early healing phase.
Skin Hyperpigmentation – Transient hyperpigmentation (darkening of the skin), especially in darker- skinned people, occurring three to eight weeks after laser therapy.
Cellulitis or Skin Infections – Cellulitis or infection of the skin and soft tissues, especially if careful post-operative hygiene is not practiced.
Skin Hypopigmentation – Hypopigmentation (lightening of the skin), which occurs because of laser-induced injury to the melanocytes (pigment containing cells in the skin) and which can be permanent.
Possible Long-term Complications of CO2 Laser Skin Resurfacing Surgery:
Increased susceptibility to sun – Because of the permanent thinning of the
Please initial after reading this page ________
epidermis and dermis and reduction in the number of melanocytes (pigment
cells in the skin), there is probably a lifelong risk of greater susceptibility of CO2 laser skin resurfaced areas to the photo-aging effects of sunlight and the carcinogenic (cancer-producing) effects of ultraviolet wavelengths inherent in
sun exposure or the use of tanning devices. For these reasons, avoidance of sun exposure or protection against ultraviolet light damage to your skin by the use of sun-screening or sun-blocking lotions with SPF (sun-protective factor) of 30 or higher is strongly advised.
The risk of scarring exists in all cases. It is variable and is often related to an individual’s genetic makeup. Scarring can be reduced by carefully following appropriate aftercare instructions and notifying the physician if a problem develops.
Skin Pigment Changes – Skin color and texture changes may occur. At the junction of the treated and untreated areas, there may be a difference in color, texture and/or thickness of the skin.
Infection – Infection is a risk that occurs in any invasive or surgical procedure. It is minimized by proper surgical technique and proper post-operative care.
Ectropion – Cicatricial (scarring or shrinkage) ectropion (out-turning of the eyelid) and/or punctal (tear hole) eversion can occur, despite optimal surgical technique.
Blepharoptosis – Blepharoptosis (drooping of the eyelid) can result from inadvertent injury to structures in the upper eyelid, especially in thin-skinned people.
Please initial after reading this page ________________
PATIENT CONSENT
I understand that exposure to the sun and excess heat must be avoided at all costs for a period of 6 months. No unprotected sun bathing is permitted for 6 months. To do so would encourage skin pigment changes and rhytids (wrinkles) necessitating further treatment.
I understand this is an elective procedure and that CO2 laser skin resurfacing surgery is not reversible.
I also understand that more than one resurfacing procedure may be required to achieve the optimal obtain- able results.
I understand the practice of medicine and surgery is not an exact science and I acknowledge that no guarantees have been made to me concerning the results and procedure. It is not possible to state every complication that may occur as a result of CO2 laser skin resurfacing surgery. Complications or a poor outcome may manifest weeks, months or even years after CO2 laser skin resurfacing surgery.
My surgeon has explained CO2 laser skin resurfacing surgery and its risks, benefits and alternatives and has answered all my questions about the CO2 laser skin resurfacing surgical procedure. I therefore consent to having CO2 laser skin resurfacing surgery.
Patient Signature Date
Chalazion: Incision and Drainage of Chalazion Consent Form
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Consent Form for Incision and Drainage of Chalazion
Condition and Proposed Treatment
Your ophthalmologist has evaluated you and diagnosed you with a chalazion, which is a localized inflammatory response involving sebaceous glands of the eyelid that occurs when the gland duct is obstructed. A chalazion may resolve spontaneously or with warm compresses, lid scrubs, and lid massage. When there is no improvement, the chalazion may be incised and drained. After local anesthesia, a chalazion instrument is put in place and an incision is made in the inner aspect of the eyelid. The contents of the chalazion are then carefully drained with a curette followed by gentle pressure or heat to control any bleeding.
Alternatives to Surgery
1. Lid Hygiene – Warm compresses, lid massage and scrubs; may not improve
chalazion if deep.
2. Steroid Injection – May require more than one injection. Can result in depigmentation of the eyelid, steroid deposits at the injection site, or in rare instances occlusion of retinal and choroidal blood vessels with possible loss of vision
3. No Treatment – I may choose no treatment and tolerate the chalazion.
Risks and Complications
No procedure is entirely risk free. Adverse effects from incision and drainage of chalazion may include:
1. Infection – Infections can be treated with topical or oral antibiotics
2. Bleeding – Normally controlled with gentle pressure or heat cautery at the incision site.
3. Pain – Minimal and resolves with healing of incision.
4. Recurrence – Chalazion may recur if incomplete excision.
5. Loss of lashes in the involved area
6. Eyelid notching in the area of the inflammation
7. Damage to the globe from the scalpel, needle used to inject the anesthetic, or cautery instrument.
8. Vision loss, including blindness.
Consent for Treatment
By signing below I acknowledge that I have read and understand the above, and have had my questions answered by the surgeon to my satisfaction. I consent to the incision and drainage of the chalazion on the _______________(state “upper” or “lower”) lid of my _________ (state “right” or “left”) eye.
________________________ _________________________ ________
Patient Name Patient Signature Date
Juvederm Consent Form
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Consent for use of JUVEDERMTM and JUVÉDERM™ Ultra
Indications
JUVEDERMTM and JUVÉDERM™ Ultra injectable gel are injected into areas of facial tissue where moderate to severe facial wrinkles and folds occur. It temporarily adds volume to the skin and subcutaneous tissues, may give the appearance of a smoother skin surface and may help smooth moderate to severe facial wrinkles and folds.
Correction is temporary; therefore, touch-up injections as well as repeat injections are usually needed to maintain optimal correction. Less material (about half the amount) is usually needed for repeat injections. Most patients need one or possibly two treatments to achieve optimal wrinkle smoothing. The results may last as long as 9 months to 1 year.
Alternatives
Other treatments for dermal soft-tissue augmentation include but are not limited to, products such as Radiesse, Restylane, Hylaform, Cosmoderm and Perlane. Aside from these treatments, additional options for the correction of lines and wrinkles do exist, including facial creams, BOTOX® Cosmetic (Botulinum Toxin Type A), chemical peels, and laser skin surface treatments, and surgery. Other options not mentioned here may exist. All options should be discussed with your physician.
Side Effects and Complications
Most side effects are mild or moderate in nature, and their duration is short lasting (7 days or less). The most common side effects include, but are not limited to, temporary injection-site reactions such as : redness, pain/tenderness, firmness, swelling, lumps/bumps, bruising, itching, infection and discoloration.
In the first 24 hours after injection, you should avoid strenuous exercise, extensive sun or heat exposure, and alcoholic beverages. Exposure to any of the above may cause temporary redness, swelling, and/or itching at the injection sites. If there is swelling, you may need to place an ice pack over the swollen area. You should ask your physician when makeup may be applied after your treatment.
Be sure to report any redness and/or visible swelling that lasts for more than a few days, or any other symptoms that cause you concern.
Contraindications
JUVEDERMTM and JUVÉDERM™ Ultra injectable gel should not be used if you have:
• Severe allergies marked by a history of anaphylaxis or history or presence of multiple severe allergies
• A history of allergies to Gram-positive bacterial proteins
The following are important treatment considerations for you to discuss with us and understand in order to help avoid unsatisfactory results and complications:
• Please inform us prior to treatment: If you are using substances that can prolong bleeding, such as aspirin or ibuprofen, as with any injection, may experience increased bruising or bleeding at the injection site.
• Please inform us prior to treatment: If you are on immunosuppressive or therapy used to decrease the body’s immune response, as there may be an increased risk of infection
• Please inform us prior to treatment: If you are pregnant or breastfeeding,
• Please inform us prior to treatment: If you have history of excessive scarring (e.g., hypertrophic scarring and keloid formations) and pigmentation disorders.
If laser treatment, chemical peeling, or any other procedure based on active dermal response is considered after treatment with JUVEDERMTM and JUVÉDERM™ Ultra injectable gel, there is a possible risk of an inflammatory reaction at the treatment site
The safety and effectiveness of JUVEDERMTM and JUVÉDERM™ Ultra injectable gel for the treatment of areas other than facial wrinkles and folds (such as lips) have not been established in controlled clinical studies. Use in patients under 18 years has not been established
PATIENT’S ACCEPTANCE OF RISKS
I have read the above information and have discussed it with my physician. I understand that it is
impossible for the doctor to inform me of every possible complication that may occur. No guarantees about results have been made. By signing below, I agree that my doctor has answered all of my questions and that I understand and accept the risks, benefits, and alternatives of JUVEDERMTM and JUVÉDERM™ Ultra
_______________________________ _________________________
Patient Signature Date
