LASER TREATMENT CONSENT FORM


IMPORTANT INFORMATION:  Please read and complete  all sections of the consent forms electronically. Ensure a  witness (a friend or family member is acceptable)  is present to fill out their required sections  clearly and legibly. Confirm that  all fields, including the witness's details, are  completed prior to submission.

ONLY SIGN IF YOU FULLY AGREE AND UNDERSTAND

I fully understand the procedure

Possible outcomes - both short and long term

Risks specific to the patient - inclusive of the possible impact of comorbities/patient history (can affect results)

Anaesthesia includes:

- Tumescent/local
- IV Sedation
- I understand the risks involved in the above

Oral analgesia will be provided post operatively.

Recovery times and specific care requirements

Possibility of the need for revision procedure/s or further treatment - both short and long term (extra expense to the patient)

Risks and Complications:

The most common risks and/or complications of laser skin ablation are:

Pain
Mild pain may be experienced with treatment, and can be treated with analgesia (usually settles within 1-2 hours). Sun sensitivity may be persistent.

Bleeding
This is extremely rare. If you have any history of excessive bleeding, or if you are taking any medications that interfere with the coagulation of the blood, notify your Doctor prior to treatment.

Swelling or redness
Local redness may appear following treatment, sometimes forming a crust, which falls off within a few days. The redness may be persistent. If there is no swelling it should disappear within 3-5 days.

Infection
In any surgical intervention there is a danger of infection. Oral antibiotics can be taken or antibiotic creams applied for a few days after treatment.

Changed pigmentation
Darkening/lightening of the treated area is seen in some patients. It is very important to protect the treated area from exposure to the sun for up to three months following the treatment. In some people, this change of pigmentation, may occur despite protection from the sun. In any case this hyper-pigmentation (darker colour) or hypo-pigmentation (lighter colour) usually fades in 3-6 months. In some cases, the condition may be treated with medication. Hypo- pigmentation may possibly be permanent and may not occur for several months after treatment.

Herpes Simplex
Herpes may appear even in those who have no previous history of this condition. It can be prevented with medication (eg. Valaciclovir) before and after the treatment. Valaciclovir should not be used by pregnant or nursing women. This medication must be taken as directed.

Wrinkles
Recurrence of wrinkles, in high movement areas such as the frown and crow's feet, can happen quite rapidly if wrinkle relaxer is not used in conjunction with this treatment.

Acne
Reactive acne, especially to paraffin used, may occur.

Scarring
Any medical procedure runs the risk of scarring. This is possible after infection, especially under the eye area (Ectropion and/or Entropion and other eye damage). This may require surgical correction.

Unexpected side effects
May include persisting pain or coincidental side effects specific to the individual.


Alternatives to Laser Skin Ablation
There are several alternative treatments to laser ablation, including surgical treatments (ie. face lift, eyelid surgery and chemical peel treatments), or no treatment at all.

Potential benefits of Laser Skin Ablation
The most obvious benefit of skin ablation by laser is its ability to treat and improve the look of aged or damaged skin. Laser ablation may be a more precise, less painful procedure than the alternatives.

agree to allow these photographs to be used for publication or teaching purposes. If I agree I understand that my identity will be kept confidential and protected. Clinical photographs will be stored in a dedicated iPad.

Having discussed the reasonable expectations of my procedure with me, and having had all my questions answered to my satisfaction, I authorise Dr Glenn Murray and assistants of his choice, to perform this procedure and any other procedure(s) that in their judgement may be necessary or advisable should unforeseen circumstances arise during surgery. I understand that the practice of medicine is not an exact science and although good results are expected, there can be no guarantee as to the results.

I understand that photographs will be used solely for clinical purposes unless I have explicitly given my consent by signing a separate photograph release form. I am responsible for taking my own photographs for my records. 

Your procedure will be performed at Suite 1/21 Stirling HWY, Nedlands, WA, 6009.


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Consent needs to be signed at least 7 days prior to surgery.

A copy of the signed consent has been provided to me.

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I certify that I have discussed all the above with the patient and have answered all questions regarding the procedure. I believe that the patient fully understands what I have explained and answered.

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Dr. Glenn Murray

Registered Medical Practitioner (MED0001196978) 

Medical Fellow of ACCSM - Australasian College of Cosmetic Surgery and Medicine.


Interpreter's Declaration (if applicable)

I declare that I have interpreted the dialogue between the patient/person(s) responsible and doctor/ healthcare provider to the best of my ability and have advised of any concerns about my interpreting of this dialogue.

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Sample Form V3 - March 2024