|
IV SEASONS SKIN CARE
HANS R. KUISLE, M.D.
WINFIELD HARTLEY, M.D.
2525 4th Street, Suite 204
Boulder, CO 80304
(303) 938-1666
Fax: (303) 443-7124
www.drkuisle.com
NEODYNIUM: YAG VASCULAR LASER CONSENT FORM
I, ______________________________________________authorize Hans Kuisle,
M.D.,
Winfield Hartley, M.D. or their designated representative to
perform Neodynium: Yag Vascular Laser therapy for___________________________________________________________________________
_________________________________________________________________________.
The Neodynium: Yag Vascular Laser is a device that produces an intense
burst of invisible laser light that
treats the abnormal blood vessels
seen in spider veins or other cutaneous vascular lesions without harming
the surrounding tissue.
To protect my eyes from the intense light, I will have my eyes covered
with an opaque material or wear
laser protective glasses.
Other methods of treating facial or lower extremity cutaneous vascular
lesions have been discussed with me.
I have been informed that scarring, hypopigmentation and hyperpigmentation
are possible risks and complications
of this procedure. Depending on the size and color of the lesion being
treated, complete clearing may not be
possible or require multiple treatments
for the
best results. The average number of treatments required for
cutaneous
vascular
lesions is three.
Anesthesia is usually not necessary. If the Physicians or I elect
to use a form of anesthesia, options will be discussed with me.
I consent to the taking of photographs during the course of my
laser therapy for the purpose of medical education.
I understand that immediately following the laser treatment, the
area may appear as a red or bruised discoloration and
slightly
swollen. I understand any discoloration may last up to14 days
and swelling
for
a
few hours, up to several days.
Improper care of the treated area
while the discoloration is present may increase the chance of
scarring, skin
textural
changes or pigment changes to the treated area.
I have read and understood all information presented to me before
signing this consent.
______________________________________________
Patient
___________________________
Date
_______________________________________________
Witness
_______________________AM
/ PM
Time
Jan 04 aan
|
