Sciton Broad Band Light (BBL) HERO Consent Form

Procedural Description: BroadBand Light (BBL), also referred to Photofacial, assists in the treatment of the following skin conditions:

▪ Hyperpigmented Lesions 
▪ Acne
▪ Skin Tightening and skin texture
▪ Bruising
▪ Rosacea & Broken Capillaries

Sciton BBL Device: The BBL 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. Such absorption produces heat, which in turn destroys the undesirable target tissues. 
The body’s natural healing process then absorbs the damaged tissue and allows for regrowth 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. Your care will be provided by a qualified BBL operator that has been trained in laser science, use of equipment, laser safety, skin care and other necessary areas of knowledge. 

Safety: All standard safety precautions and all BBL-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.

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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 and that it is my responsibility to explore such options prior to BBL therapy. I have explored such alternatives to my satisfaction, and have made an independent decision to proceed with BBL treatments.

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Limitations: I understand that some rejuvenation is achieved in nearly everyone, but that complete rejuvenation may not occur. Results are limited by the equipment capability as well as personal skin characteristics. My Fitzpatrick skin typing has been analyzed, and I understand that a higher Fitzpatrick typing increases the potential risk of the treatment. Currently, Photorejuvenation is limited to skin types I- IV. 

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Hormonal therapy and other medical conditions may affect my results. These issues will be discussed at the time my medical history is reviewed. Results are cumulative; therefore a series of treatments is necessary to achieve maximum benefit. Actual results cannot be guaranteed.

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Cautions: If I am subject to keloid formation, excessive scarring or poor healing (diabetes or other conditions) I will consult my personal physician prior to proceeding. I will avoid sun tanning, tanning booths and tanning creams for at least 4 weeks prior to and after all BBL treatments as this will reduce the effectiveness and increase side effects. I understand that Accutane (or similar products containing tretinoin) should not be used for 6 months and Retin-A (or similar products containing isotretinoin) should not be used for at least 2 weeks prior to treatment. 

I will not use glycolic acid or other alpha hydroxyl acid products for 1 week prior to treatment. I understand that treatments cannot be done on skin areas with open sores or lesions. I understand that tattoos and permanent makeup may be altered and that moles may be lightened. I understand that recurrent viral infections such as herpes simplex (cold sores) or varicella (shingles) may be activated and that hair growth in the treated area may be affected. If I have a personal or family history of skin cancer, I have been advised to consult a specialist before having pigmented lesions treated. Prior to any treatment, I will advise Body360MedicalAesthetics of any history of excessive bleeding or bruising, if I am taking an anticoagulant (blood thinning) medication (including aspirin), if I have sun sensitivity or am using any sun sensitizing medications, hormones, steroids, Accutane, Retin-A or similar products or contraceptives. 

I agree to provide accurate personal and medical history prior to treatment. I understand that all reflective objects such as jewelry and watches must be removed if near the treatment area.

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Pre and Post Treatment Instructions: I acknowledge receipt of pre and post treatment instructions. I understand that failure to follow these may affect my treatment outcome and increase the likelihood or severity of complications.

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Skin Changes: I understand that I may experience temporary redness similar to sunburn. Some skin swelling (edema) may occur especially following facial treatments. Bruising, blistering, scabbing, infection and other skin changes are also possible, although much less likely. I understand that in most cases, all of these effects should resolve over the next several hours to days following treatment. I understand that cold compresses are beneficial, and in extreme cases a mild steroid cream or antibiotic may be necessary. 

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Scarring is extremely rare and usually occurs in those with a predisposition such as a history of keloids or other excessive scarring, but acknowledge that scarring is possible with any patient. I have been advised not to undergo BBL treatments if I have such a history and under these circumstances acknowledge that Body360MedicalAesthetics cannot be held responsible for the outcome of my treatments. I agree to carefully follow the post treatment instructions to reduce the likelihood or severity of any skin changes.

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Pigment Changes: I understand that hypo-pigmentation (decreased skin coloration) or hyperpigmentation (increased skin coloration) is uncommon, but if it occurs to me, although rarely permanent, may last several weeks to months. I understand that post treatment use of sunblock is advised to minimize the risk, and that in some cases bleaching creams add additional benefit.

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Long Term Risk: I understand that the risks of BBL use may not fully known. The information presented to me is based on recent studies conducted over a relatively short period of time. Although considered safe, Body360MedicalAesthetics cannot be held responsible for any BBL risk not yet discovered or commonly known.

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Continued Consent: I agree that this consent shall apply to all subsequent treatments of a similar nature. Guarantee: I understand that although every reasonable effort will be made to achieve a desirable outcome no guarantees are stated or implied. I do___ I don’t___ want photographs to be taken of me during my treatments. I understand that my pictures will not be used in any advertising without my consent, but to be left in my file for future reference for myself and the clinical staff.

I certify that I am a competent adult of at least 18 years of age (Minors (under 18 years of age) require additional consent from a parent or legal guardian.)

My signature attests to the fact that I have fully read this entire consent form, that I have had any concerns answered to my satisfaction, that I understand and agree to this information contained within, and accept the risks inherent in undergoing this procedure. I hereby consent to the use of the Sciton Broad Band Light (BBL) system for the treatments specified above.