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Informed Consent for Intense Pulse Light (IPL) Laser Treatment
In our ongoing efforts to provide you with the best possible service, we ask that you
carefully review this procedural consent form and ask any questions necessary to help
you fully understand it. Please also obtain pre and post-care instruction on our website
under Resources or ask our office to print you a copy.
Procedure: Intense Pulsed Light (IPL) systems are used for photo-rejuvenation. Photo-
rejuvenation assists in the treatment of the following skin conditions: vascular changes,
including telangiectasias (spider veins), and the redness and flushing symptoms of
rosacea. Pigmentary changes, including brown spots, sunspots and lentigines,
dyschromia and other conditions brought about by sun damage and photo-aging.
Enlarged pores, poikiloderma and melasma. Generalized aging of the skin.
Mechanism: The IPL system produces a broad beam of highly concentrated light. This
light is filtered to a wavelength that is selectively absorbed by the target tissues with
minimal effect on surrounding tissues. This absorption produces heat, which in turn
alters the undesirable target tissues. The body's natural healing process then absorbs
the affected tissue and allows for re-growth of healthy tissue. The duration
(milliseconds) and energy (fluence) of the light pulse are adjusted for your specific skin
characteristics to achieve maximum benefit. The target is usually abnormal
pigmentation or small, unsightly blood vessels.
Safety: All required safety precautions and all IPL-specific guidelines will be followed to
ensure the utmost in safety during your treatments. This includes the use of protective
eyewear at all times while the equipment is in use. We recommend removal of contact
lenses during facial treatments.
Alternatives: I am aware of alternative methods of treatment such as topical chemical
products and other light-based or laser systems. I realize that various other alternative
services may be available. I understand that my concerns regarding the condition of my
skin may be caused by various medical conditions that may require other forms of
treatment that I should discuss with the provider. I have explored such alternatives to
my satisfaction, and have made an independent decision to proceed with IPL
treatments.
Limitations: I understand that some rejuvenation is achieved in nearly everyone, but
that results vary widely from patient to patient. My results are limited by the equipment
capability as well as by my personal skin characteristics. Fitzpatrick skin typing will be
assessed prior to treatment.
I understand that the higher the Fitzpatrick skin type, the greater the potential risk of the
treatment. To reduce the occurrence of side effects, we limit photo-rejuvenation
treatments to skin types I -IV.
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Hormonal therapy and other medical conditions may affect my results. These issues will
be/were discussed at the time my medical history is/was reviewed. Results are
cumulative; therefore a series of treatments is necessary to achieve maximum benefit.
Actual results cannot be guaranteed.
I understand that Intense Pulse Light is not intended to substitute for a surgical facelift,
ablative skin resurfacing, or procedures that treat deep wrinkles and sagging skin. It is
intended for patients desiring evenness of color in their complexions, or those showing
signs of sun damage and photo aging. Intense Pulse Light skin treatments have a great
appeal to individuals with active lifestyles who cannot set aside healing time, as
required with ablative procedures or surgery. The procedure requires no "downtime",
i.e., patients can resume all activities immediately after treatment, except sun exposure.
Cautions: I understand that hair follicles in the treated area may be permanently
affected, resulting in reduced hair growth. I under-stand that I should not undergo facial
IPL treatments unless I am willing to accept a reduced ability to grow facial hair. If I am
subject to keloid formation (thickened scars), excessive scarring or poor healing (due to
diabetes or other conditions) I will consult my primary care physician prior
to proceeding.
I understand that tattoos and permanent makeup in the treatment area may be altered
and moles may be lightened. I understand that recurrent viral infections such as herpes
simplex (cold sores) or varicella (shingles) may be activated. If I have a personal or
family history of skin cancer, I have been advised to discuss this with the provider
before you proceed.
Prior to any treatment, I will advise Paz Dermatology of any history of excessive
bleeding or bruising, if I have sun sensitivity or am using any sun sensitizing
medications, hormones, steroids, Accutane, Retin-A or similar products, or
contraceptives. I understand that all reflective objects, such as jewelry and watches,
must be removed if near the treatment area.
Further Contraindications include, but are not limited to the following:
• Current or history of cancer, especially malignant melanoma, or recurrent non-
melanoma skin cancer, or pre-cancerous lesions such as multiple dysplastic
nevi.
• Any active infection.
• Disease which may be stimulated by light at 560nm to 1200nm, such as history
of recurrent Herpes simplex, systemic lupus erythematosus, or porphyria.
• Use of photosensitive medication and / or herbs that may cause sensitivity to
560-1200m light exposure such as isotretinoin, tetracycline, or St John's Wort
(Best Avoided for at least one year before your procedure).
• Immunosuppressive disease, including AIDS and HIV infection, or use of
immunosuppressive medications.
• Patient history of Hormonal or endocrine disorders, such as polycystic ovary
syndrome or diabetes, unless under control.
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• History of bleeding coagulopathies, or use of anticoagulants.
• History of keloid or hypertrophic scarring.
• Very dry skin.
• Exposure to sun or artificial tanning during the 3-4 weeks prior to treatment.
Sunblock should be applied 2 weeks or more before your procedure using a
product that is sensitive for the skin and contains titanium dioxide or zinc oxide-
containing sunblock.
• Skin type V1 or very dark, black skin types
• Pregnancy and nursing.
• Ectropion, outward turning of the lower eyelid and excessively dry eyes, previous
lower blepharoplasty.
• Koebnerizing diseases, prior radiation therapy leading to a loss of adnexal
structures, extensive fibrosis resulting from prior cosmetic treatments (e.g.,
Dermabrasion, deep chemical peels, silicone injections).
Discomfort: I understand that the sensation generated by the light pulse is most
commonly described as a rubber band snapping against the skin, and most
individuals are able to tolerate this for the short duration of the treatment. I
understand that I will have a sunburn-type sensation in the treatment area for
several hours afterwards, and that topical anesthetics are available to decrease any
perceived discomfort from the IPL treatment. If I desire a topical anesthetic, I will
discuss this with my medical provider.
Skin Effects: I understand that acceptable results will likely take a number of
treatments, usually four to six. The entire program should be planned at the outset
so that you can have a set schedule to come in and to help you to have realistic
expectations. Most people will typically experience transient temporary redness,
bruising, swelling and flaking of pigmented areas. Discomfort can occur when a
pulse is triggered in various degrees. Some describe the sensation as stinging, while
others liken it to a rubber band snap. A burning sensation may last up to an hour
after treatment. Some skin swelling (edema) may occur especially following facial
treatments. Excessive swelling can occur immediately after treatment, especially
around the nose and eyes the skin may swell temporarily. Swelling usually subsides
within hours to as much as seven days. Bruising, blistering, scabbing, infection and
other skin changes are also possible, although much less likely. Very rarely, a blue-
purple bruise may appear on the treated area. It may last from 5 to 15 days. As the
bruise fades, there may be rust-brown discoloration of this skin, which fades in 1 to 3
months. You can have damage to skin texture. A crust or blister may form, which
may take from 5 to 10 days to heal. I understand that in most cases, all of these
effects should resolve themselves within a few hours to several days following
treatment.
Burns: There is a small chance of burns occurring on the skin. To reduce the
possibility of burns from occurring, it is important to carefully follow all treatment
instructions, and in particular performing test patches can be an option. I understand
that cold compresses and recommended skin care products may be beneficial, and
in extreme cases a mild steroid cream, to reduce swelling or antibiotic may be
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necessary to prevent infection. After Treatment the skin at or near the treatment site
may become fragile. If this happens, avoid makeup and do not rub the area, as this
might tear the skin. Scarring is extremely rare and usually occurs in those with a
predisposition such as a history of keloids or other excessive scarring. To reduce the
chance of scarring, it is important to carefully follow all post-treatment instructions
and exclude patients that have a genetic tendency for scarring.
I understand that IPL can cause pigmentation changes such as hypo-pigmentation
(decreased skin coloration) or hyper-pigmentation (increased skin coloration) and,
although rarely permanent, may last several weeks to months. For up to 15 days
following treatment, pigmented lesions may become darker. I understand that post-
treatment use of sunscreen is advised to minimize this risk, and that in some cases
bleaching creams may provide additional benefit. I have been advised not to
undergo IPL treatments if I have such a history and under these circumstances
acknowledge that Paz Dermatology cannot guarantee the outcome of my
treatments. I agree to carefully follow the pre and post-treatment instructions to
reduce the likelihood or severity of any adverse skin changes. Intense Pulse Light is
typically administered in a series of four to six treatments, performed at intervals of a
minimum of three weeks.
A 3-week interval has proven optimal. However larger intervals do not appear to
adversely influence treatment results. Spreading the treatment over this period
provides a gradual improvement of the skin, a minimal risk of adverse effects, and
preserves the important "no downtime" feature of the program. In rare cases where
side effects do occur, postpone further treatments until after complete healing. The
most common side effects are:
Long Term Risk: I understand that the risks of IPL treatments may not be fully
known. The information presented to me is based on clinical studies conducted over
a relatively short period of time. Although considered safe, Paz Dermatology cannot
be held responsible for any IPL risk not yet discovered or commonly known.
Continued Consent: I agree that this consent shall apply to all subsequent IPL
treatments.
Guarantee: I understand that although every reasonable effort will be made to
achieve a desirable outcome no guarantees are stated or implied.
Authorization: I certify that I am a competent adult of at least 18 years of age. My
signature attests to the fact that I have fully read this entire consent form, that I have
access to the pre and post care instructions published on the website or available for
print by Paz Dermatology, and that my questions or concerns have been answered to
my satisfaction. I understand and agree with the information contained herein, and
accept the risks inherent in undergoing this treatment. I hereby consent to the use of the
IPL system in the hopes of attaining the desired benefits. I have read and understand
the above consent and agree to proceed with the IPL treatment series.