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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
MICRO LASER PEEL
Informed consent: Patients have a right to be informed of facts,
consider goals of and alternatives to the treatment being offered.
Please read all
the information herein and sign below when you agree to treatment.
Facts about Micro Laser Peel: The Micro
Laser Peel is a superficial epidermal exfoliation to a light dermal
resurfacing skin treatment.
The depth is
controlled by the energy of the erbium:YAG laser, and is predetermined
by evaluation of patient’s desires and treatment goals. Treatments
are administered by a licensed medical esthetician under the supervision
of Hans R. Kuisle, M.D. &/or Winfield Hartley, M.D.
Conditions treated: Micro Laser Peel is a smoothing or polishing
procedure for the skin. Conditions treated are uneven pigmentation,
fine or epidermal
lines, acne, acne scars, actinic keratoses and keratinization
(build-up of dead skin). The goal of the procedure is removal
of damage with
the intent of improving vitality of the skin. Deeper treatments
yield more
significant improvement, but also have more downtime for healing.
Goal of treatment: Patient may discuss goals with the Physician
and the Esthetician. There can be no guarantee made as to anticipated
results.
Results will vary according to skin type and condition upon
starting treatment. It is strongly recommended that a program
of home
skin care product usage
be undertaken to further any gains made with the treatments.
A series
of 4 treatments at 3 month intervals are suggested, followed
by a maintenance
protocol of treatment and home care.Alternatives to treatment:
Micro Laser Peel is offered as an alternative to other methods
of non-invasive
exfoliation,
such as enzymatic, alpha/beta hydroxy acid or chemical peeling.
It is not intended to replace surgery, dermabrasion or ablative
laser
resurfacing.
Surgical intervention may be necessary to treat dermal scarring
or tighten loose skin.
I understand the foregoing and consent to treatment with the
Micro Laser Peel.
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Patient Signature
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Date
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