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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
PATIENT
INFORMED CONSENT
PULSE DYE VASCULAR LASER
I, ______________________________________________authorize Hans R. Kuisle,
M.D., or his designed
representitive to perform Pulse Dye Vascular
Laser therapy for____________________________________
____________________________________________________________________________________
.
The Pulse Dye Vascular Laser is a device that produces an intense
but gentle burst of laser light that treats the abnormal blood
vessels seen in spider
veins or other cutaneous vascular lesions without harming the surrounding
tissue. The Laser also treats some types of facial wrinkles by
stimulating new collagen formation deep in the skin, without
harming the skins outer
layer.
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, or facial wrinkles, 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 3 to 5. For wrinkle reduction, a series of
4 treatments,
with follow
up treatments averaging yearly.
Anesthesia is usually not necessary. If Dr. Kuisle 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 Signature
___________________________
Date
_______________________________________________
Witness
_______________________AM
/ PM
Time
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