LASER/ RF TREATMENTS
burns, blistering, pain, discomfort, scarring, excessive swelling, keloid, hyperpigmentation, hypo-pigmentation, purpura, textural changes, infection, sensitive skin, reduced sweating.
PRP / MICRONEEDLING/ RADIOFREQUENCY MICRONEEDLING
DISCOMFORT: Usually minimal and of short duration.
SWELLING: Occurs rarely and is usually minimal, typically subsides within a few hours or days. The skin may feel tight after the treatment. REDNESS: Redness may persist for a few hours to a few days.
CRUSTING/SCABBING: On rare occasions, a superficial crusting may occur, typically this is localized, but can be seen over larger areas.
PIGMENTATION: Although extremely rare, temporary or possibly permanent changes in color of the skin may occur.
MILIA: Whiteheads or acne may occur but will usually disappear quickly.
INFECTION: Infections are unlikely but may occur. An outbreak of fever blisters may occur in affected individuals. If you are prone to fever blisters, please inform your provider and a prescription will be provided.
CHEMICAL EXFOLIATION/ADVANCED RESURFACING/HYDRAFACIAL
Stinging, itching and irritation, Redness and possible swelling, Tightness, peeling, or scabbing of the treated skin and surrounding areas, Prolonged skin sensitivity, I understand that I may or may not peel and that the amount of peeling does not correlate with the degree of effectiveness or improvement.
Allergic reaction is uncommon from treatment. Some persons may have a hive-like appearance in the treated area. Some persons have localized reactions to cosmetics or topical preparations. Systemic reactions are rare.
By signing this form, you confirm that (i) you read, understand and agree to the above items, (ii) you have been fully informed regarding the procedure(s), risks and side effects, and (iii) you knowingly, freely and voluntarily give consent to have the procedure performed, Salameh Plastic Surgery & Medical Spa’s staff have fully explained the procedure to be administered. I have had a chance to ask questions which were answered fully to my satisfaction. Potential side effects have been explained to me. I understand there is no guarantee of results from the treatment and the possible risks associated. This consent, acknowledgement and understanding form is valid for every visit I make with Salameh Medical Spa and Skin Care.
I understand the procedure is elective and accept the risks. I hereby release Salameh Plastic Surgery & Medical Spa, its employees and contractors from all liabilities associated with the procedures performed. Moreover, I certify and state that I have received no promises, assurances, or guarantees from anyone as to the results that may be obtained by any treatment or services. I agree any self-publication including posting, broadcast or transfer of personal information by you on the internet, a blog, website, or other printed /electronic form constitutes a waiver of any protections afforded such personal health information under any applicable regulations, rules or laws. Any self-publication of your personal information permits Salameh Plastic Surgery & Medical Spa to respond to the original publications to the extent necessary to defend, limit and challenge the assertions made in such publications. Any and all comments and publications will be considered self-disclosed waived protections of your personal information.
I certify that I am a competent adult of at least 18 years of age. This consent form is binding upon my spouse, relatives, legal representatives, heirs, administrators, successors and assignees.