Loading...

Informed Consent

Skin Treatment

ACKNOWLEDGMENT, WAIVER, AND CONSENT TO RECEIVE LASER SKIN REJUVENATION PROCEDURE. DO NOT SIGN THIS FORM WITHOUT READING AND UNDERSTANDING ITS CONTENTS. 


1. Skin Rejuvenation Procedure

Bared Monkey offer the best aesthetic technology, such as, M22™ IPL Photofacial, PicoWay™, PicoSure Pro™ Laser for vascular and pigmentation removal, AviClear™, Hydrafacial, VI Peels, PCA Peels, Clarity™ II Laser Genesis, Hollywood Spectra Q-switch laser for mild to sever acnes treatments, Secret™ RF Microneedling, ResurFX™ laser, Picoway® Resolve™, LaseMD Ultra treatment for firming up tissue, remodeling collagen, improving fine lines, wrinkles, skin texture and diminishing scars, etc. 

The Picoway® & Picosure Pro™  are the most powerful Pico laser for benign pigmentation such as freckles, age spots, lentigines, and the stubborn pigmentation such as Nevus of Ota, Café-au-Lait, Melasma and more. It delivers the highest power in the shortest pulses in the market at 200ps which reduce the thermal impact and boost photoacoustic effect. Patients can enjoy a radiant and renewed look with minimum downtime and side effects.


The M22 IPL™ photofacial treatment targets brown and red pigment in the skin. They can also target the bacteria that causes acne, reducing its severity, along with stimulating collagen production, to help firm skin and reduce the look of fine lines and wrinkles.


The Lumenis ResurFX™ treatment is a fractional skin rejuvenation solution that addresses the early signs of aging, helps even out hyperpigmentation (like sun spots or melasma), smooth wrinkles, and fade stretch marks and mild acne scars.


The AviClear™ Laser is indicated for the treatment of mild to severe inflammatory acne vulgaris. It utilize 1726 nm wavelength to selectively targets this exact frequency to damage the sebocytes and down-regulate sebum production which eliminate acnes at its source. 


The HydraFacial is the FDA-approved hydradermabrasion procedure that combines cleansing, exfoliation, extraction, hydration and antioxidant protection simultaneously, resulting in clearer, more beautiful skin with little-to-no downtime. The treatment is soothing, moisturizing, non-invasive and generally non-irritating. As with most procedures, visible results from HydraFacial will vary from person to person.   


The VI Peels/PCA Peels treatments can be used to diminish the appearance of fine lines and wrinkles, improve texture/tone, reduce pore size, increase hydration and moisture retention, give skin a smoother appearance and diminish the appearance of hyperpigmentation. Layers of product are applied based on your unique skin composition and needs.


The LaseMD Ultra™ Skin Resurfacing is the “true Thulium” laser for skin revitalization. The laser creates tiny “microchannels” in the skin which increases the absorption of compounds. It helps rebuild glowing and healthy skin, reduce appearance of pore size and enhance brightness, in addition, the laser energy stimulates dermal repair, promote healing, regeneration, and collagen formation to give the entire surface a healthy and beautifully noticeable radiance.


The Secret™ RF’s Microneedling treatment deliver energy at various depths in the epidermis and dermis to induce collagen regeneration while sparing the skin’s surface. Secret RF can be used to improve your skin quality by reducing signs of photo aging and photo damage, fine lines and wrinkles, stretchmarks and scars/acne scars. Unlike other devices which only deposit energy on the surface of the skin, Secret RF delivers energy below the surface where it's needed most to help revitalize and regenerate the skin. This unique delivery of energy allows us to achieve the optimum results with little to no downtime on all skin types. 


The Clarity II™ Laser Genesis delivering a therapeutic dose of energy from the laser, the upper dermis (middle layer of the skin) receives enough heat to stimulate the growth of collagen, elastin, and new skin cells. To diminish redness; reduce rosacea, inflamed acnes, smooth texture and reduce pore size, the laser targets small facial capillaries within the target layers of skin. The thermal coagulation and vaporization (ablation) of the affected tissue that results, along with collagen production, are the key changes that restore the structural balance within the skin so that a youthful glow may be achieved after a series of sessions.


The Hollywood Spectra Laser toning is a fast and comfortable treatment that uses a Q-switched Nd:YAG laser energy in ultra-short pulses to target and break down pigmentation, acne scars and other skin imperfections without damaging the surrounding tissue.

The advantage of a Hollywood Spectra peel in comparison to other treatments is the minimal downtime. With minimal side effects, most people have the treatment over lunchtime or just before a special event.


The purpose of the above mentioned procedures is to improve the appearance of photo-aged skin by clearing the superficial pigmented and vascular lesions, promoting collagen growth and thus improving the skin texture. However, the degree of improvement and the number of sessions required vary in clients with variables such as age, condition of your skin, sun damage, smoking, skin care products, climate, life-style, and general health, you acknowledge that there are no guarantees, warranties or assurances that you will be satisfied with your results.

 

2. What we can treat?

  • Melasma
  • Birthmarks
  • Sun damage and brown spots
  • Broken Capillaries/Rosacea and redness
  • Fine lines and wrinkles
  • Freckles
  • Acne
  • Hyperpigmentation and scarring
  • General skin tone and texture

 

3. Risks and Side Effects:


• Discomfort: Mild to moderate discomfort is typical during treatment. If a patient reports severe discomfort, the treatment should be paused, and the settings verified and/or adjusted accordingly.

• Erythema and edema: Mild to significant erythema (redness) and mild to moderate edema (swelling) developing during and immediately after treatment are expected. Mild erythema typically resolves within 30 minutes to several hours, significant erythema and edema may take up to 1 week to subside; Application of cold packs immediately after treatment may reduce the severity and duration of both.

• Transient acne flareups: Mild flareups of inflammatory acne lesions are common after acne treatment. If acne flareups occur, they typically maximize 2 to 5 days after treatment and resolve over 2 to 3 weeks ; however, acne flareups can continue at perceptible levels for several more weeks.

• Temporary skin dryness: Temporary mild skin dryness is common after skin resurfacing treatment. If skin dryness occurs, it is normally noticed 1-5 days after treatment and typically resolves in 1 to 2 weeks with application of topical skin moisturizers (e.g., CeraVe®, Cetaphil®); however, it can persist up to 4 weeks.

• Crusting/scabbing:Mild crusting or scabbing may occur during healing process. If crusting/scabbing occurs, the crusts/scabs should be allowed to naturally slough, without picking, to minimize the likelihood of skin pigmentation changes or infection.

• Blisters: Mild to moderate blisters are very rare. If blisters do develop, care should be taken not to disturb or unroof the blisters to prevent oozing and possible infection. Oozing from blisters that are disturbed or unroofed lasting more than a day should be evaluated by the treating practitioner.

• Hyperpigmentation: Darkening of the skin (hyperpigmentation) can occur as a result of inflammation during the recovery period. If it occurs, it may last for one to several months before normal pigmentation levels return. Hyperpigmentation is very rarely permanent. Your treating practitioner may recommend topical skin-lightening products to accelerate the return to normal pigmentation levels.

• Skin texture changes: Transient texture changes are rare and usually resolve with time.

• Infection: Despite good wound care, pain, swelling, oozing, and fever can indicate the development of an infection. This is rare though it can occur. Topical and/or oral antibiotics may be necessary.

• Scarring: Scarring is a rare occurrence, but it is a possibility whenever the skin's surface is disrupted. To minimize the chances of scarring, it is important that patients follow all post-treatment instructions provided by their health care provider. Good post-treatment care will help reduce the possibility of scarring.

• Hypopigmentation: Lightening or loss of skin pigment (hypopigmentation) is very rare. Transient hypopigmentation lasting several weeks has been reported following crusting/scabbing. Permanent hypopigmentation has not been reported; however, it is a possible adverse event, especially in patients with a history of vitiligo or pigmentary disorders.

• Bruising: broken capillary blood vessels may lead to transient “mini-bruising”. Sun avoidance is essential in that case


4. Pre-Procedure Instructions

  • Excess hair may need to be shaved. Men should be cleanly shaved prior to the treatment.
  • No excessive sun exposure, sun tanning or self tanner 4 weeks prior to treatment.
  • Use a broad spectrum UVA/UVB sunscreen with an SPF of 50 or higher. Apply to the treated area every 2 hours when exposed to the sun and it is recommended to make this a part of your skin care routine.
  • Avoid skin irritants (i.e. product containing tretinoin, retinol, benzoyl peroxide, glycolic/salicylic acids, vitamin C/Ascorbic acid, astringents etc.) for 5-7 days before treatment. 
  • Notify us with any changes to your health history or medications since your last appointment. 
  • History of herpes or cold sores may require an antiviral prescription prior to the treatment. 
  • Remove all makeup, lotions, creams or oils prior to treatment. 

 

5. Post-Procedure Instructions

  • Mild to significant erythema (redness) and mild to moderate edema (swelling) developing during and immediately after treatment are expected. Mild erythema typically resolves within 30 minutes to several hours, significant erythema and edema may take up to 1 week to subside; Application of cold packs immediately after treatment may reduce the severity and duration of both.
  • Immediately post-treatment, apply a broad spectrum (UVA/UVB) SPF 30+ sunblock and recommend to apply on a daily basis, re-applying every 90-minutes if outside. 
  • Cold compresses or chilled gel packs may be applied post treatment for patient comfort.
  • If crusting/scabbing occurs, do not rub or pick on the area. Apply Aquaphor ointment or other moisturizer to the treated area 2-3 times a day. Keep the area moist and let the crusting/scabbing resolve on its own.
  • Avoid sports or any other activity that could lead to excessive perspiration. 
  • Avoid swimming, soaking or using hot tubs/whirlpools until the skin heals.
  • Direct and prolonged sun exposure should be minimized throughout the duration of the treatment regimen.

  • Starting the morning after treatment, it's recommended wash face with a gentle cleanser followed with a gentle moisturizer (e.g., CeraVe®, Cetaphil®) twice a days for 7-10 days.
  •  Client can resume their regular skin care regimen 7 days after treatment.
  • Makeup can be used after 24-48 hours depending on the skin response.
  • Some patients experience dryness and itching of the treatment area up to 4 weeks post treatment. Avoid plucking/rubbing the skin to avoid further complications. 
  • With any acne treatments, post Inflammatory flare ups typically occur 7 or more days after treatment, and can last up to 3 weeks. It's recommended only use non-comedogenic skin products during skin recovery period. 
  • Avoid skin irritants (i.e., products containing tretinoin, retinol, benzoyl peroxide, glycolic/salicylic acids, astringents, etc.) for 5-7 days pre and post treatment.
  • Avoid treatments that may irritate the skin for 1-2 weeks after treatment (waxing, depilatories, etc.). 

Client should contact our office with any concerns, such as blistering, excessive or prolonged redness/swelling, etc.

 

I hereby authorize Bared Monkey MedSpa Inc. and all its affiliated companies. and the trained, licensed staffs in this practice to perform the laser skin rejuvenation procedure on me. And I clearly understand the following:

1. The potential benefits of the proposed procedure(s).

2. The possible alternative procedure(s).

3. The probability of success of my selected procedure.

4. The goal of Skin Rejuvenation, as in any cosmetic procedure, is improvement, not perfection.

5. There is no guarantee that the expected or anticipated results from the treatments will be achieved.

6. For best results, I have been informed that multiple treatments are needed. More treatments may be needed depending on skin type and photo-aging severity.

7. Hormonal imbalance, pregnancy, menopause, and skin conditions such as rosacea and melasma can affect treatment outcomes.

8. Tanning during the course of my laser treatments is not recommended and can cause a number of complications. My scheduled treatment may be postponed if I am too tan. 



I have been given copies of both pre and post care instructions and the pre and post-care instructions have been discussed and are completely clear to me. 

I understand that sun exposure, as well as not adhering to the post treatment instructions provided to me may increase the chance of any complications. I have been informed to use a sunblock with an SPF of 30 or higher on the treated area during the course of laser treatments. And It is my responsibility to inform the center of any medical or prescription changes or if my skin is any darker than when I first started treatment.


I acknowledge there are possible complications/risks involved with the proposed procedure and subsequent healing period, including pigmentary changes, scarring and changes to skin texture. I am aware that careful adherence to all advised instructions will help reduce this possibility.


I confirm that I am not pregnant and do not intend to become pregnant anytime during the course of treatment. Furthermore, I agree to keep Bared Monkey MedSpa Inc. and all its affiliated companies and staff informed should I become pregnant during the course of treatment.


I acknowledge photographic documentation may be taken.


 

I have read and understood all information presented to me, and I have been given an opportunity to ask questions before signing this consent. I acknowledge and accept the risks inherent in the laser skin rejuvenation procedure. I voluntarily assume the risk of possible complications and side effects which may arise from the laser skin rejuvenation Treatment set forth herein; and any of my heirs, executors, representatives or assigns hereby release Bared Monkey MedSpa Inc. and all its affiliated companies from any and all claims, liabilities for personal injury, and property damages of any kind sustained while on the premises, during the treatments set forth herein by any employees or representatives of Bared Monkey MedSpa Inc. and all its affiliated companies. 

April 19, 2024

 





First Patient's Name

First Name*

Last Name*

Phone*
First Patient's Date of Birth*
First Patient's Signature*
Second Patient's Name

First Name*

Last Name*
Second Patient's Date of Birth*
Third Patient's Name

First Name*

Last Name*
Third Patient's Date of Birth*
Fourth Patient's Name

First Name*

Last Name*
Fourth Patient's Date of Birth*
Fifth Patient's Name

First Name*

Last Name*
Fifth Patient's Date of Birth*
Sixth Patient's Name

First Name*

Last Name*
Sixth Patient's Date of Birth*
Seventh Patient's Name

First Name*

Last Name*
Seventh Patient's Date of Birth*
Eighth Patient's Name

First Name*

Last Name*
Eighth Patient's Date of Birth*
Ninth Patient's Name

First Name*

Last Name*
Ninth Patient's Date of Birth*
Tenth Patient's Name

First Name*

Last Name*
Tenth Patient's Date of Birth*
Patient's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Ethnicity
Please specify your genetic origin:
African American
Asian
Caucasian
Hispanic
Mediterranean
Middle Eastern
Native American
Other
Females Only
Are you pregnant?*
No
Yes
N/A
Are you planning pregnancy during the course of your treatments?*
No
Yes
N/A
Medical and Surgical History
Do you have any of the following medical conditions? (please check all that apply)
Active Severe or Cystic Facial Acne
Open facial wound or lension
Metal stents in the treatment area
Implants
Migraines
Bell's palsy
Hemorrhagic or bleeding disorders
Active or local skin disease
Autoimmune Disease
Epilepsy
Herpes or Cold sores
Diabetes
Rosacea
Skin cancer
Psoriasis/Eczema
Gold Theraphy
History of bleeding coagulopathies
HIV or hepatitis
Pacemaker
Vitiligo

Are you currently being treated for any skin condition not listed above? (if NONE please notate "N/A"): *
Do you have any natural or artificial sun exposure in the past 4-6 weeks?*
No
Yes
Do you have any application of self - tanners within the past 2-3 weeks*
No
Yes
Do you use any photosensitive herbal preparations (St John's Wort, Ginkgo Biloba, etc...) or aromatherapy?*
No
Yes
Do you have any inflammatory skin conditions (dermatitis, active acne, eczema, rash etc...)?*
No
Yes
Any presence or history of active cold sores or herpes simplex virus:*
No
Yes
Do you have infection, skin laceration or scarring on treatment site?*
No
Yes
Do you have active or previous cancer (currently on chemotherapy or radiation)?*
No
Yes
Do you have medical history of keloids or poor wound healing?*
No
Yes
Do you intake of isotretinoin within the past year?*
No
Yes
Do you have immunocompromised conditions (for example: uncontrolled diabetes)?*
No
Yes
Do you have Bleeding coagulopathies or usage of anticoagulants?*
No
Yes
Do you have Gold salts (as part of rheumatoid arthritis treatment)?*
No
Yes
Any presence of tattoos on the treatment area?*
No
Yes
Any injections, fillers or implants on treatment site within the past 3 months?*
No
Yes
Any laser skin resurfacing treatment, Microdermabrasion, Chemical Peels, Ablative or non-ablative laser treatment in the past 6 weeks?*
No
Yes

Have you used any skin irritants on the treatment area (i.e. products containing tretinoin, retinol, benzoyl peroxide, glycolic/salicylic acids, astringents, etc.)? (if NONE please notate "N/A"): *

Please list all medications you are currently taking in the 6 months and/or other consideration (if NONE please notate "N/A"): *

Please list any known allergy? (if NONE please notate "N/A"): *
Skin Typing:

Please answer the following questions by selecting the number which BEST describes you. 

Eye Color:*
0. Light color
1. Blue, gray or green
2. Hazel/Light brown
3. Dark brown
4. Black
Natural Hair Color:*
0. Sandy red
1. Blond
2. Chestnut or dark blond
3. Brown
4. Black
Your natural skin colour (unexposed area)*
0. Reddish
1. Pale
2. Beige and olive
3. Brown
4. Dark Brown
If you stay in the sun too long?*
0. Painful, redness, blistering and peeling
1. Blistering followed by peeling
2. Burn, mild peeling
3. Rare burn
4. Never had burns
Do you turn brown after several hours of strong sun exposure?*
0. Never
1. Seldom
2. Sometimes
3. Often
4. Always
To what degree do you turn brown?*
0. Hardly or not at all
1. Light color tan
2. Reasonable tan
3. Tan very easily
4. Turn brown quickly
How does your face react to the sun?*
0. Very sensitive
1. Sensitive
2. Normal
3. Resistant
4. Never have a problem
How often do you tan?*
0. Never
1. Seldom
2. Sometimes
3. Often
4. Always
When was your last tan?*
0. +3 months ago
1. 2-3 months ago
2. 1-2 months ago
3. A few weeks ago
4. A few days ago
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver - TRY IT FREE!