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VascuLyse Consent

CONSENT FOR TREATMENT WITH VASCULYSE 2G

VascuLyse 2G will free you of unsightly and unpleasant skin conditions: broken capillaries, skin tags, milia, and cholesterol deposits. Treatments with the VascuLyse 2G are safe and non-invasive. During the procedure the stylus simply touches the skin surface. Most vascular blemishes disappear on contact.

Areas to be treated:

         I do not have any of the conditions (pacemaker, metal implant, diabetes, pregnancy, medical condition delaying healing process, blood thinning drugs) contraindicated with VascuLyse treatments.

          I understand that with any treatment, certain risks are involved and that complications or side effects from known or unknown causes may occur. I freely assume these risks.

         Side effects may include mild redness, extreme redness, local swelling, bruising, tenderness, stinging, darkening of the skin, infections. Most side effects are temporary and generally subside within one week to 21 days.

         I have been advised not to touch or rub the treated area, not to pick scabs and to let them fall off by themselves. I understand that I must keep the area clean and use hydrating and healing products, avoid sun exposure for one week, and use total sunblock on the treated area until healing is complete.

         Treatment will be withheld if cold sores, inflammatory acne or other eruptions occur as the procedure can cause the eruption to spread. The procedure should be deferred until the skin is perfectly healed.

         I agree to comply with all safety precautions and home skin care programs as recommended by my therapist or practitioner, and I will inform her/him of any concerns or complications as soon as they occur.

         I am over 18 years of age.

While satisfactory results are often achieved with one treatment, some cases may require more treatments. There is no way to guarantee that the desired result will reflect the end result. Your own body and biological response is a major factor in the result process.

I have read the above information and have discussed the risks and benefits of this procedure to my satisfaction with my physician and/or assigned healthcare professional.

I recognize that not having this procedure is an option.

I recognize that this is a cosmetic procedure and that there is an associated fee.