MDs @ QUEENSWAY MEDICAL | Premier Medical and Cosmetic Center
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Laser Treatment Consent Form- CLARITYII

I understand that CLARITYII treatment (Long-pulsed Alexandrite & Nd: YAG laser) is intended for the treatment of pigmented lesions, vascular lesions, hair removal and skin rejuvenation and that treatment is commonly performed over facial and non-facial areas.

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By signing below, I acknowledge that I have read the foregoing informed consent and agree to the treatment with its associated risks. I hereby release the doctor prescribing Latisse and the facility from liability associated with this procedure.

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CLARITYII pigmented lesion treatment break melanin particle by long-pulsed Alexandrite laser. Short-term side effects such as redness, swelling, mild burning sensation or fine crusts of the sk are not uncommon. Pinpoint bleeding may also occur depends on patient skin condition.

CLARITYII vascular lesion treatment collapses the targeted vessel wall for improving the lesion. Short-term side effects such as redness, swelling, bruise, mild burning sensation or fine crusts of the skin are not uncommon. There is a rare possibility that a scar at the treatment site may develop.

Common side effects include temporary redness and mild "sunburn" like effects that may last a few hours to 3-4 days or longer.

CLARITYII skin rejuvenation treatment renews skin cell by apply thermal effect in dermis layer. Short-term side effects such as redness, swelling or mild burning sensation of the skin are not uncommon.

Just as there are benefits to the procedure proposed, I understand that this procedure also involves risks and downtime to heal. I understand that serious complications are rare but possible. I understand that clinical results may vary depending on my response to surgery and my compliance with pre and post-treatment instructions. I understand that no guarantee has been given to me with regard to the percentage of improvement of my skin and that more than one treatment is recommended to achieve the desired results. I have read and understand this form and my questions have been addressed and answered to my satisfaction. 1 have read pre­treatment considerations and post-treatment instructions and I will follow the recommendations outlined to protect my akin.

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