Patient Consent for SilkPeel, Dermalinfusion System
The SilkPeel system is a safe and highly effective treatment for simultaneous exfoliation of the skin with delivery of a topical formula to target a specific dermatological condition. Exfoliation promotes the reduction of fine lines wrinkles, minor scars, acne, stretch marks and sun damage. It also regenerates the epidermal cell structure resulting in skin elasticity and a more youthful, pliable, smooth skin. Topical formulas penetrate the skin to treat specific conditions such as acne, hyper-pigmentation, photo damage, dehydration, fine lines and wrinkles. The SilkPeel treatment performed with your practitioner’s recommended pre- and post- treatment skin care regime promotes optimal outcomes.
I hereby authorize and direct any associates or employees of Vasu, Inc to perform the SilkPeel on me. Multiple treatments are required to achieve cosmetically acceptable results. I specifically acknowledge that no guarantees or warranties have been made concerning the results of the procedure.
The following points have been discussed with me and I understand: (please initial each statement)
I acknowledge that I might experience a scratchy, stinging sensation during the treatment. This sensation will subside during the post-treatment protocol.
I acknowledge that if I suffer from acne, the condition may temporarily look worse after the treatment, but will improve after additional treatments.
I understand that if I fail to use sunscreen, I am more susceptible to sunburn and hyper-pigmentation. Exercise should be limited after the treatment for 24 hours.
I hereby authorize Vasu, Inc or any associates to take pictures of the treated area to be used in my patient file and/or teaching purposes. I understand that the release of this information will be kept confidential and that no patient names will be used.
I acknowledge that I have not been on Accutane for acne therapy during the past six months. I acknowledge that I have not been using Retin-A for the past two weeks. I will discontinue the use of Retin-A for 1-3 days after treatment.
I have been given the opportunity to ask questions about the procedure(s). My questions have been answered and I understand the information given to me.
Contraindications to the performance of this procedure(s) have been discussed in detail with me and I understand that my skin’s condition may actually temporarily worsen as a result of this treatment.
I acknowledge that facial telangiectasia (small blood vessels) is sometimes more apparent immediately after the treatment when the skin is thin and will diminish after re-epithelialization (build up of dead cells).
I agree to remove my contact lenses prior to the procedure (if applicable)
I acknowledge that if I am prone to cold sores (herpes) around the mouth or facial area, I may need a prescription for Zovirax (or another medication recommended by my physician) from my medical doctor prior to having the treatment and avoid all treatments during breakouts.
I understand that technician will use tools that are either disinfected or disposable.
I acknowledge that my skin might experience temporary tightness, redness or slight swelling which disappears in a few hours depending on my skin’s sensitivity.
I am NOT pregnant or lactating (females).
I do NOT have rosacea.
I do NOT have salicylate or aspirin sensitivity.
I understand and agree to give at least 24-hour cancellation or re-scheduling notice and I agree to pay a minimum of $50.00 or forfeit my treatment if I don’t give proper notification. If I cancel the same day of my scheduled appointments, I agree to pre-pay for any future appointments. Such payment will be non-refundable and non-transferable.
I understand that I release Vasu, Inc and its associates, the Medical Director, the technician performing the procedures and any other person involved in my treatment from any liability associated with complications from my SilkPeel procedure. By my signature below, I certify that I have read and fully understand the contents of this permission and authorize the performance of the SilkPeel Dermalinfusion treatment by the staff of Vasu, Inc.