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Consent Form

The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy. Implementation of HIPAA requirements officially began on April 14, 2003. Many of the policies have been our practice for years. This form is a “friendly” version. A more complete text is posted in the office.

What this is all about: Specifically, there are rules and restrictions on who may see or be notified of your Protected Health Information (PHI). These restrictions do not include the normal interchange of information necessary to provide you with office services. HIPAA provides certain rights and protections to you as a patient. We balance these needs with our goal of providing you with quality professional service and care. Additional information is available from the U.S. Department of Health and Human Services. www.hhs.gov

We have adopted the following policies

Patient information will be kept confidential except as is necessary to provide services or to ensure that all administrative matters related to your care are handled appropriately. This specifically includes the sharing of information with other healthcare providers, laboratories, and health insurance payers as is necessary and appropriate for your care. Patient files may be stored in open file racks and will not contain any coding which identifies a patient’s condition or information that is not already a matter of public record. The normal course of providing care means that such records may be left, at least temporarily, in administrative areas such as the front office, examination room, etc. Those records will not be available to persons other than office staff. You agree to the normal procedures utilized within the office for the handling of charts, patient records, PHI, and other documents or information.

It is the policy of this office to remind patients of their appointments. We may do this by telephone, e-mail, U.S mail, or by any means convenient for the practice and/or as requested by you. We may send you other communications informing you of changes to office policy and new technology that you might find valuable or informative.

The practice utilizes a number of vendors in the conduct of business. These vendors may have access to PHI but must agree to abide by the confidentiality rules of HIPAA.

You understand and agree to inspections of the office and review of documents which may include PHI by government agencies or insurance payers in the normal performance of their duties.

You agree to bring any concerns or complaints regarding privacy to the attention of the office manager or the doctor.

Your confidential information will not be used for the purposes of marketing or advertising products, goods, or services.

We agree to provide patients with access to their records in accordance with state and federal laws.

We may change, add, delete or modify any of these provisions to better serve the needs of both the practice and the patient.

You have the right to request restrictions in the use of your protected health information and to request changes in certain policies used within the office concerning your PHI. However, we are not obligated to alter internal policies to conform to your request.

I do hereby consent and acknowledge my agreement to the terms set forth in the HIPAA Information Form and any subsequent changes if office policy.  I understand that this consent shall remain in force from this time forward.

IPL/RF Consent Form

Laser/IPL/RF Consent Form I consent to authorize Clariti Medspa & Wellness to perform Laser/IPL/RF treatments on me. Light can be used effectively to destroy targets located in the skin with minimum damage to the surrounding tissues. Light is used to lighten, fade or remove photodamaged skin, veins, and/or tattoos in a non-ablative manner. Visible signs of photodamage include wrinkling, enlarged pores, course skin texture, and pigment alterations. I certify that I do not have any of the following conditions which are CONTRAINDICATIONS to laser treatment: history of melanoma, raised moles, suspicious lesions, keloid scar formation, active infections, open lesions, hives, active herpetic lesions, tattoos, or permanent makeup in an area of treatment, use of medications such as Accutane, Tetracycline, or St. John’s Wort in the last year, autoimmune diseases such as lupus, scleroderma, vitiligo, or have used sunless tanning products in the last 10 days. I certify that I am not pregnant, trying to get pregnant, or nursing. I have informed my technician of my recent sun exposure and if I have had any, I understand the risks of skin discoloration with treatment. Phototherapy, despite its high levels of efficacy and safety, is not free of side effects. Erythema (redness) and edema (swelling) of the treated area can occur but usually subsides within a few hours, but can last up to seven days or longer. Irritation, itching, and/or a mild burning sensation or pain (similar to a sunburn) may occur within 48 hours of treatment. I understand that the treatment may be painful, but this is typically managed without any pain medications. Pigment changes, such as hyperpigmentation or hypopigmentation, of the skin in the treated areas can occasionally occur. Most often, it is transient, lasting up to six months, but in rare cases can be permanent. Most cases of hyper- or hypo-pigmentation occur in people with darker skin or when the treated area has been exposed to sunlight before or after treatment. Occasionally, these pigment changes can occur despite appropriate protection from the sun. Unprotected sun exposure in the weeks following treatments are contraindicated as it may cause pigmentation changes or worsen the condition. Scarring, which can be hypertrophic or even keloid, can occur. Other known complications of this procedure include blisters, reddening, pinpoint pitted scars, bruising, superficial crusting, burns, pain, and infection. These side effects are usually temporary, lasting from five to ten days but can be permanent as well. The skin at or near the treatment site may become fragile. If this happens, makeup should be avoided and the area should not be rubbed, as this might tear the skin. A blue-purple bruise may appear on the treated areas, which might last several days. As the bruise fades, there may be rust-colored brown discoloration of this skin, which typically fades in one to three months. Additionally, there is a known and expected loss of hair in the treated areas. In a very small percent of people, there is new hair growth in the surrounding areas being treated. Even though appropriate measures are taken to reduce side effects, they cannot be completely eliminated in every case. I understand that the treatment may involve risks of complications or injury from both known and unknown cases, and I freely assume all risks. There may be other treatment options, such as injections, other types of laser/light therapy, or chemical peels. With this in mind, I am choosing this non-invasive treatment for vascular and/or pigment lesions and/or tattoo removal and other indicated skin conditions. Eye damage can occur from the light and therefore protective eyewear must be worn during all phototherapy sessions. I have read and understand the Pre- and Post-treatment instructions. I agree to follow these instructions carefully. I understand that compliance with recommended pre and post-procedure guidelines is crucial for healing, prevention of scarring, and other side effects and complications, such as hyperpigmentation, hypopigmentation, and other textural changes. I understand that this treatment is not meant to replace the necessity for a complete dermatological examination. No guarantee, warranty, or assurance has been made to me as to the results that may be obtained. I am aware that follow-up treatments may be necessary for desired results. Most clients require a number of treatments over several months with gradual results occurring over this time. I agree to adhere to all safety precautions and regulations during the treatment. No refunds will be given for treatments received. The nature and purpose of the treatment have been explained to me. I have read and understand this agreement. All of my questions are answered to my satisfaction and I consent to the terms of this agreement. Alternative methods of treatment and their risks and benefits have been explained to me and I understand that I have the right to refuse treatment. I release Clariti Medspa & Wellness, staff, and specific technicians from liability associated with this procedure. I certify that I am a competent adult of at least 18 years of age.

Microneedling Consent Form

I hereby authorize the practitioner or any delegated associates to perform Microneedling Therapy. I understand that this procedure is purely elective.

What to expect

  • Depending on the area of your face or body being treated and the type of divide used (i.e. needle length), the procedure is well-tolerated and in some cases virtually painless, feeling only a mild prickling sensation.
  • Your practitioner will apply a topical anesthetic to your skin prior to treatment to reduce any pain and discomfort.
  • Your skin will be pink or red in appearance, much like a sunburn, for a couple of hours following treatment.
  • Minor bleeding and bruising are possible depending on the length of the needle used and the number of times it is pressed across the treatment area.
  • Your skin may feel warm, tight, and itchy for a short while. This should subside in 12-48 hours.

Possible Side-Effects

  • Side effects or risks are minimal with this type of treatment and typically include minor flaking or dryness of the skin with scab formation in rare cases.
  • Milia (small white bumps) may form; these can be removed by the practitioner.
  • Hyper-pigmentation (darkening of certain areas of the skin) can occur very rarely and usually resolves after a month.
  • If you have a history of cold sores, this procedure may cause flare-ups.
  • Temporary redness and mild-sunburn effects may last up to 4 days.
  • Freckles may temporarily lighten or permanently disappear in treated areas.
  • Other potential risks include crusting, itching, discomfort, bruising, infection, swelling, and failure to achieve the desired results. Permanent scarring (less than 1%) is extremely rare.

The benefits and risks of the procedure have been explained to me, and I accept these benefits and risks. The nature of my medical or cosmetic condition has been explained to my satisfaction as have been any substantial or significant risks of harm. I am also aware of and accept the risk of rare and unforeseen complications which may not have been discussed and which may result from this treatment.

I have had the opportunity to ask questions and seek clarification of this procedure and its alternatives including no treatment and my questions have been answered satisfactorily.

I understand the following contraindications listed below and will notify my provide if any of the following apply to me:

  • Active infections – viral, fungal, bacterial
  • Rashes, warts, skin cancer
  • Active acne
  • Immune-suppressed patients
  • Skin-related autoimmune disorders
  • Pregnant or breast-feeding
  • Patients on anticoagulants (NSAIDs, ASA, Coumadin/Warfarin)
  • Recent ablative dermal procedures
  • Rosacea
  • Diabetes
  • Actinic (solar) keratosis
  • Keloids

Acknowledgment by my signature below, I certify that I have read and fully understand the contents of this permission form for microneedling and that the disclosures referred to herein were made to me.

Non-Ablative Skin Therapy 

I hereby authorize the practitioner, and any delegated associates to perform Non-Ablative Skin Therapy on me. I understand that this procedure works on promoting vibrant and healthy looking skin by creating a thermal response in the dermis that stimulates new collagen. I understand that multiple treatments are required and it is possible the result will be minimal or not help at all.

I am aware of the following possible experiences/risks:

Discomfort

A slight warming sensation may be experienced during treatment.

Redness/Swelling/Bruising

Short-term redness (erythema) or swelling (edema) of the treated area is common and may occur. There also may be some bruising.

Pigment Changes ( Skin Color)

During the healing process, there is a possibility that the treated area can become either lighter (hypopigmentation) or darker (hyperpigmentation) in color compared to the surrounding skin.This is usually temporary, but, on a rare occasion, it may be permanent.

Wounds

Treatment can result in burning, blistering, or bleeding of the treated areas. If any of these occur, please call our office.

Infection

Infection is a possibility whenever the skin surface is disrupted, although proper wound care should prevent this. If signs of infection develop, such as pain, heat, or surrounding redness, please call our office.

Scarring

Scarring is a rare occurrence, but it is a possibility if the skin surface is disrupted. To minimize the chances of scarring, it is IMPORTANT that you follow all post-treatment instructions carefully.

Eye Exposure

Protective eyewear (shields) will be provided. It is important to keep these shields on at all times during the treatment in order to protect your eyes from injury.

The following points have been discussed with me:

  • Potential benefits of the proposed procedure
  • Possible alternative procedures such as topicals, microdermabrasion, or surgery
  • Probability of success
  • Reasonably anticipated consequences if the procedure is not performed
  • Most likely possible complications/risks involved with the proposed procedure and subsequent healing period

For women of childbearing age: By signing below I indicate that I am not pregnant. Furthermore, I agree to keep the practitioner and staff informed should I become pregnant during the course of treatment. Photographic documentation will be taken.

Acknowledgment by my signature below, I certify that I have read and fully understand the contents of this permission form for nonablative laser treatment and that the disclosures referred to herein were made to me.

Pre-IPL

Pre nonablative skin therapy instructions

  • Avoid sun exposure (apply sunscreen daily and do not tan at all – including self-tanner) for 2 to 3 weeks before and after treatments.
  • Do not use any retinol products (or products containing tretinoin) or exfoliants on the area to be treated for one week. Avoid Accutane (or isotretinoin products) for 6 months prior. Let your doctor know if you have a history of hyperpigmentation.
  • You must notify the technician if you have had any cosmetic tattooing on or near the area to be treated.
  • Photosensitizing medications including doxycycline and minocycline should be discontinued three days prior to the treatment.
  • Anticipate a social “down-time” of 3-5 days before any redness, or swelling has subsided.

Post-IPL

The sunburned feeling and swelling usually last 1-3 hours. Applying ice will give relief and reduce the swelling duration. The redness will last a few days but can be covered up by applying makeup.

Your skin will be fragile. Use gentle cleansers, do not rub the skin, and avoid hot water during this time. Do not use your Clarisonic or a loofah for one week.

Makeup can be applied immediately (if the skin is not broken); we recommend mineral-based makeup.

Avoid the sun and use sunblock for 4 to 6 weeks. Avoid excessive heat or friction to the treated area (heavy exercise, saunas) for one week. Please contact us as soon as possible if you experience any blistering or increased pain. Contact us if you are concerned about infection. If any pigment changes are bothersome or persist beyond 4 weeks, please contact our office.

Microneedling Pre

Prior to the Microneedling session, please observe the following:

  • No Retin-A products or applications 24 hours prior to your treatment.
  • No auto-immune therapies or products 24 hours prior to your treatment.
  • No prolonged sun exposure to the face 24 hours prior to your treatment. A Microneedling treatment will not be administered on sunburned skin.
  • On the day of the treatment, please keep your face clean and do not apply makeup.
  • If you are taking a blood thinner, aspirin, or any other medication that you have the propensity to bleed easily while on, please tell your technician. If you are under a physician’s care and need to discontinue your medication for a few days, always ask your physician prior to each Microneedling appointment.
  • If you are planning to receive Botox, make sure that you give yourself at least 2 weeks post Botox injections before receiving your Microneedling procedure.
  • If an active or extreme breakout occurs before treatment, please consult your practitioner. Wait 6 months following oral isotretinoin use.

Microneedling Post

After your treatment, please be aware and observe the following:

Immediately after your treatment, you will look as though you have a moderate to severe sunburn and your skin may feel warm and tighter than usual. You may also notice some slight swelling, both are normal and should subside after 1 to 2 hours and will normally diminish within the same day or 24 hours. You may see slight redness after 24 hours but only in minimal areas or spots.

If you are concerned about any reaction, please call our office and contact your healthcare provider immediately.

After-care instructions for MicroNeedling Treatment:

  • Use tepid water for the initial 24 hours to rinse the treated area. After 24 hours, use a gentle cleanser to cleanse the face for the following 72 hours and gently dry the treated skin. Always make sure that your hands are clean when touching the treated area.
  • Do not take any inflammatory medicines for at least 2 weeks post-treatment.
  • It is recommended that makeup or sunscreen should not be applied for 24 hours after the procedure. Do not apply any makeup with a makeup brush, especially if it is not clean.
  • After the initial 24 hours, apply a broad spectrum UVA/UVB sunscreen with a minimum of SPF 30 for two weeks. A chemical-free sunscreen is highly recommended.

What to Avoid

  • For at least 3 days post-treatment, do NOT use any Alpha Hydroxy Acids, Beta Hydroxy Acid, Retinol (Vitamin A), Vitamin C (in a low pH formula) or anything perceived as ‘active’ skincare.
  • Avoid intentional and direct sunlight for 48 hours. No tanning beds.
  • Do not go swimming for at least 24 hours post-treatment.
  • No exercising or strenuous activity for the first 24 hours post-treatment. Sweating and gym environments must be avoided during the first 72 hours post-treatment.

RF/ Non-Ablative PRE

  • Avoid sun exposure (apply sunscreen daily and do not tan at all – including self-tanner) for 2 to 3 weeks before and after treatments.
  • Do not use any retinol products (or products containing tretinoin) or exfoliants on the area to be treated for one week. Avoid Accutane (or isotretinoin products) for 6 months prior. Let your doctor know if you have a history of hyperpigmentation.
  • You must notify the technician if you have had any cosmetic tattooing on or near the area to be treated.
  • Photosensitizing medications including doxycycline and minocycline should be discontinued three days prior to the treatment.
  • Anticipate a social “down-time” of 3-5 days before any redness, or swelling has subsided.

RF Non-Ablative Post

  • Avoid sun exposure (apply sunscreen daily and do not tan at all – including self-tanner) for 2 to 3 weeks before and after treatments.
  • Do not use any retinol products (or products containing tretinoin) or exfoliants on the area to be treated for one week. Avoid Accutane (or isotretinoin products) for 6 months prior. Let your doctor know if you have a history of hyperpigmentation.
  • You must notify the technician if you have had any cosmetic tattooing on or near the area to be treated.
  • Photosensitizing medications including doxycycline and minocycline should be discontinued three days prior to the treatment.
  • Anticipate a social “down-time” of 3-5 days before any redness, or swelling has subsided.