Consent Form For Treatment By Pigment Laser

The undersigned:

Patient:

Resident of

Physician:

1. INTRODUCTION

The contents of this form give a brief overview of the information exchanged and explained during the preceding oral conversations between both parties.

The patient is considered to be well informed before consenting to receiving pigment laser treatment.

It is obvious that the treating physician is prepared to answer all your possible questions regarding this operation.

2. NATURE AND COURSE OF THE TREATMENT

The pigment laser is a device producing highly energetic light. During the treatment, a laser beam is pointed at the skin. The laser beam selectively destroys the melanin pigment or tattoo particles in the skin, while the surrounding tissues are left untouched. In general, local anesthesia is not needed. In case it should be necessary for one or another reason, the treating physician will discuss the modalities thereof in detail. During laser treatment, the patient, the physician and the personnel are to wear special glasses to protect the eyes against the laser light.

3. AIM OF THE TREATMENT

The aim of the treatment is to clear up a lesion caused by melanin pigment or tattoo particles. The number of treatments depends on the extent, the nature, the age and the intensity of the pigmentation of the skin lesion. A complete disappearance of the treated lesion is aimed at, but can never be guaranteed in advance.

The physician thus agrees with the patient to operate according to the rules of art, but cannot promise any well-defined result (= commitment to make every possible effort).

4. RISKS

Potential complications of the treatment are:

- Wound infection: occurs very rarely and heals when treated appropriately.

- Formation of scar tissue: highly exceptional.

- Increased or decreased pigmentation:

In some cases, the wound heals with increased pigmentation (hyperpigmentation). This usually happens among patients with darker skin tones or as a result of sun exposure. Other patients are predestined to have this kind of reaction and may have experienced this before, during the healing of other wounds. In order to minimize the risk of hyperpigmentation, post-operational protection of the skin against sun exposure is of the utmost importance. Among some patients, this hyperpigmentation can even occur despite good sun protection. Hyperpigmentation is usually only temporary, but needs a few months to clear. Seldom does the hyperpigmentation persist nevertheless.

Among some patients, the treated area may show decreased pigmentation (hypopigmentation) and thus obtain a lighter color than the surrounding skin tissue. This is usually only a temporary reaction, after which the skin will gradually pigment again. In some cases, however, the depigmentation may be permanent.

The physician has informed the patient how to take care of the treated skin area. Not following these postoperative instructions may cause complications.

Fig. 3.8. Consent form

5. EFFECTS

Immediately after being treated, the skin will turn whitish gray. Exceptionally, erosion (superficial wound) and/or pinpoint bleeding may occur. A bluish red discoloration as a consequence of bleeding may also appear and may last up to 2 weeks before disappearing.

6. ALTERNATIVE TREATMENTS

Cryotherapy, excisional surgery and dermabrasion are possible alternatives.

7. PHOTOGRAPHS

In order to have a better view on the results of the operation, and for educational and scientific purposes, such as presentations and scientific publications, photographs may possibly be taken. The patient will be turned unrecognizable on these pictures. The patient is well informed about this and agrees to it.

8. REVOCATION OF CONSENT

The patient deliberately consents to the treatment and can at any moment decide to stop further treatment.

9. OBSERVATIONS

Observations of the physician:

Observations of the patient:

10. Each of the consenting parties declares to have received a copy of this consent form. The signature is preceded by the self-written formula 'read and approved'.

The patient declares that all his/her questions have been answered.

Patient's signature Physician's signature

Fig. 3.8. Consent form (continued)

Nd:YAG laser was developed. It is most effective for treating black ink tattoos, especially in darker skin types. The 532-nm wavelength is the treatment of choice for red tattoo pigment.

When treating epidermal pigmented lesions with the 532-nm wavelength, nonspecific vascular injury will occur, leading to purpura, which takes 5-10 days to resolve. Because of the ultrashort pulse duration, the Q-switched Nd:YAG

laser produces the greatest amount of epidermal debris. This can be minimized by the use of larger spot sizes. Recent studies have shown that larger spot sizes and lower fluences are as effective in removing tattoo pigment as smaller spot sizes at higher fluences, and have fewer side effects. Therefore, when using the 1064-nm wavelength, treatment should begin with a 4- to 8-mm spot size at 3-6 J/cm2.

Table 3.4. Suggested treatment parameters for pigmented lesions

Indication

Laser

Spot size(mm)

Fluence (J/cm2)

Lentigines

510-nm PLPD

3

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