Skin resurfacing erbium laser treatment

SKIN RESURFACING ERBIUM LASER TREATMENT Initials

CONSENT FORM
The procedure planned is SKIN RESURFACING with the Erbium:Yag laser using topical, local,

IV sedation or general anesthesia. The purpose of this procedure is to attempt to remove, fade or

significantly lighten the presenting lines in the skin and/or wrinkles. ______
Alternative treatment methods include, but are not limited to: dermabrasion, chemical peels, plastic

surgery and other laser modalities, or no treatment. ______

I understand that the risks of the procedure include possible pain, bleeding, infection and scarring.

The risk of scarring despite proper treatment exists in all cases, but can be greatly minimized by

proper aftercare. There is also risk of patchy residual pigment changes or lightening of skin color

or change in skin texture after treatment. Loss of skin pigment (usually temporary) is uncommon,

but may occur. There is risk of accidental eye injury if struck by the laser beam. This is highly

unlikely since complete eye protection is provided throughout the laser treatment session(s).

Previous treatment by any method may increase any or all of these risks. ______
I understand that this procedure may fail to remove all lines/wrinkles in the areas treated, especially

deeper lines and wrinkles. Although the area treated improves after the first treatment, some areas

may need additional treatment(s). Loss of skin pigment (usually temporary) is uncommon, but may

occur. ______

I understand my responsibility for properly fulfilling the appropriate aftercare instruction as explained

by the Doctor’s at Palm Beach Dermatology, the staff and/or as explained through written or videotape

instruction provided to me. I further agree that any pictures or videotape taken of me can be used for

either teaching or publication as Palm Beach Dermatology considers appropriate unless I notify

Palm Beach Dermatology in writing that my photographs are not to be used under such circumstances. ______
This procedure is considered cosmetic and not covered by insurance. I understand that I am

responsible for all costs of treatment. ______

I have been asked at this time whether I have any questions about this procedure and I do not.

I understand the procedure and accept the risks and request that this procedure be performed on me. ______

______________________________ ______________________________

Signature of Patient Date of Procedure

____________________________ ____________________________

Parent/Guardian Witness