11550 Jonesbridge Rd, Suite# 6, Alpharetta GA 30022
Email: info@cosmomedspaatl.com         Tel: (678) 829-7722

IPL Consent Form

I authorize Cosmo Med Spa to perform Intense Pulsed Light (IPL) treatments on me in an effort to improve Dyschromia, Hyperpigmentation, Sun Damage, Hemangioma,Angioma, Telangiectasia, Rosacea, and/or Leg veins.

I understand that there is a rare possibility of side effects or serious complications including permanent discoloration or scarring.

I am aware of the short-term side effects and agree to follow all post care instructions.

I understand that sun exposure or tanning of any sort is prohibited while undergoing these treatments.

The procedure as well as potential benefits and 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.

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.

Has the treatment area been exposed to natural or artificial sun exposure in the past 2 weeks?
Yes No

Have you used self–tanners or tan enhancers within the past 3 weeks?
Yes No

Are you currently taking any photosensitizing medications or supplements?
Yes No

Are you pregnant, suspect you may be pregnant?
Yes No

Is there a presence or history of active cold sores or herpes simplex virus?
Yes No

Have you ever had skin cancer?
Yes No

Have you taken Accutane (Isotretinoin) within the past year?
Yes No

Have you observed any modification (color, size, texture and border) on the lesion to be treated?
Yes No

THE UNDERSIGNED acknowledges that TECHNICIAN has explained the nature of allthe above noted treatment of IPL procedures including the risks and dangers inherent therein.

I HEREBY CONSENT to performing the above-noted treatment procedures on me and in consideration of their so doing;

I hereby release and forever discharge Cosmo Med Spa & Salon, from all claims, demands, damages, actions or causes of action arising out of the performance of the said treatment procedures, which I, my heirs, executors, administrators or assigns can, shall, or may have. (NO REFUND ON ANY TREATMENT)

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