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Alumier MD Consent Form

Alumier

FULL DISCLOSURE
Prior to receiving treatment, I have reviewed and signed the Patient Profile given to me by my physician/skincare
professional. I have been truthful in disclosing information that may have bearing on this procedure including the following: -Accutane use    

• Pregnancy
• Nursing/lactating  

• History of cold sores
•  Allergies 

• Aspirin allergy
•  Autoimmune illness  

• Cancer treatment

POSSIBLE ADVERSE EVENTS
I have been informed that the following may occur post-treatment
•  Hyperpigmentation/hypopigmentation: I agree to follow the recommended post-procedure instructions to minimize the chance of this occurring.
•  Allergic reaction: I also understand that exposure to different ingredients found in the treatment and associated home care products may result in an allergic reaction.
• Contact dermatitis, inflammation (redness), edema (swelling), skin irritation (itchiness)
• Temporary sensation of heat and itchiness immediately following treatment
• Scarring (rare)
If any of the above occurs, I will immediately discontinue the use of all professional treatments and AlumierMD home care products and consult my physician.


PEELING
I understand that the treated area may or may not actually peel and that each treatment is individual. I understand that the degree of peeling does not necessarily reflect the efficacy of the procedure.

 

CONDITIONS OF TREATMENT
I agree to refrain from the following activities for 14 days post-treatment Sun or tanning bed exposure

• Microdermabrasion

• Laser hair removal - Photofacials

• Chemical peels

• Laser or RF skin treatments


I agree to refrain from the following activities for 7 days post-treatment
•    Waxing, threading, and use of all other depilatories
•    Neurotoxin injections (eg. Botox, Dysport)
•    Dermal filler injections
•    Use of retinoids • Use of mechanical exfoliants
•    Use of topical AHA/BHA and all other exfoliant topical skincare products
•    Use of sunless tanning products
•    Acne topical treatments
•    I have disclosed all prescription and non-prescription products that I am using.
•    I agree to follow all post-procedure protocols recommended by my physician/skincare professional.
•    I agree to use the recommended sun protection product (SPF 30 or higher) on the treated area for a minimum of 14  days post-treatment

 

LIMITATIONS TO TREATMENT
I understand there are no guarantees as to the results of this treatment due to many variables including age, skin condition, sun damage, smoking, climate, etc. l understand that this treatment is cosmetic and that no medical claims are expressed or implied by AlumierMD or by the skincare professional. I understand that to achieve maximum results, I may require several treatments.


ADVERSE EVENTS
I understand that although adverse events are rare, they do occur and prompt treatment is necessary. In the event of any adverse event, I will contact the physician/skincare professional who performed my treatment.

 

I hereby certify that all the information that I have provided has been accurate and truthful. I acknowledge reading all the information contained herein regarding the possible adverse events associated with the treatment I will receive and acknowledge the limitations and adverse events of such treatment. I further acknowledge that these limitations and adverse events have been explained and that I accept and consent to treatment I agree to follow all post-treatment care instructions provided to me. I acknowledge that I have been provided with adequate time to read, understand and accept the above limitations and complications.

Thanks for submitting!
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