11550 Jonesbridge Rd, Suite# 6, Alpharetta GA 30022 Email: info@cosmomedspaatl.com Tel: (678) 829-7722 Laser Vein Removal Consent Form
I request and authorize Cosmo Med Spa & Salon to perform Laser Vein Removal using Cynosure Elite+. I understand that the results from the treatment vary with each individual. The purpose of this treatment is to attempt to remove, fade, or significantly lighten the vein. This treatment is not a cure for vein disease, nor will it prevent further veins from developing. Multiple treatments may be necessary. The laser produces an intense burst of light that is absorbed by the targeted abnormal blood vessel without causing damage to the surrounding tissue. All personnel in the treatment room including myself will wear protective eyewear to prevent eye damage from the intense laser light. The sensation of the light is uncomfortable and may feel like a moderate to serve hot pinprick or burst of heat that lasts for only a few seconds. If the technician elects to use some form of anesthesia, then all options will be discussed with me. Immediately following treatment, the area may appear flushed and warm, but there should be no bruising. The flushness should fade over the course of a few hours. The skin may have redness that lasts 2-3 days (similar or scratch). Following treatment, the area should be treated delicately. I have been informed that blistering, scarring, hypopigmentation (lightening of the skin) and hyperpigmentation (darkness of the skin) are possible risks and complications of this procedure. I understand that sun exposure and not adhering to post care instructions may increase my chances of complications. I will care for the skin area(s) gently cleaning daily with gentle, antibacterial cleanser and applying a broad spectrum (UVA/UVB) sun block SPF 30 or greater. The sun block should be applied before leaving the office.
Waiver Agreement THE UNDERSIGNED acknowledges that TECHNICIAN has explained the nature of all the above noted treatment of Laser Vein Removal 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.)