I am not pregnant or nursing and will notify the practitioner if I think I could be pregnant. I understand that Photofacial treatment is considered cosmetic and is not covered by insurance, therefore I am fully responsible for all costs of treatment.

I have requested that Arsenault DermSpa attempt to improve the appearance of my skin, including vascular and pigmented lesions, with the Photofacial treatment. I understand that there are NO GUARANTEES as results vary from person to person.

Side Effects and Complications:

I understand that there is a possibility of rare side effects such as scarring and skin discoloration. Short term side effects include, but are not limited to:

• Redness
• Mild burning
• Temporary discoloration of the skin
• Irritation/discomfort
• Pigmentation changes
• Increased sensitivity to the sun
• Temporary swelling, crusting, bruising, peeling, or flaking

Precautions and Contraindications

• Pregnancy/Breast-feeding
• Accutane usage in the past 18 months
• History of keloid scarring
• History of bleeding disorders
• Use of anti-coagulants
• Diabetes
• Use of medications that increase photosensitivity
• Recent or planned sun exposure

I agree that this constitutes full disclosure and that it supersedes any previous verbal and written disclosures. My signature indicates that I am consenting to receive treatment, having read and understood the information presented above and have been given the opportunity to ask any questions that I might have about this procedure. All my questions have been answered in a satisfactory manner. I have been advised of the risks involved in such treatment and alternative treatments, including no treatment at all.

I consent to be photographed before, during and after treatment. These photographs shall be the property of Arsenault DermSpa. These photographs may show for scientific reasons, and/or used in patient education (both in and out of the office).

I understand the importance of properly fulfilling the appropriate after-care instructions as explained to me and given to me in writing.

Your consent and authorization for this elective procedure is strictly voluntary. By signing this informed consent form, you hereby grant authorization to our medical staff to perform and/or to administer any related treatment as may be deemed necessary or advisable in the diagnosis and treatment of your condition.

The nature and purpose of this elective procedure and the complications and side effects have been fully explained to me. Alternative treatments and their risks and benefits have been explained to me and I understand that I have a right to refuse treatment. I agree to adhere to all safety precautions and instructions after the treatment. I have been instructed in and understand post treatment instructions and have been offered a written copy of them. I understand that no refunds will be given for treatments received. No guarantee has been given by anyone as to the results that may be obtained by this treatment.

I have read this informed consent and certify that I understand its contents in full. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement. I have had enough time to consider the information given me and feel that I am sufficiently advised to consent to this procedure. I accept the risks and complications of the procedure. I certify if any changes occur in my medical history I will notify the office.

I hereby give my voluntary consent to this elective procedure and release the facility, medical staff, and specific technicians from liability associated with the procedure. I certify that I am a competent adult of at least 18 years of age and am not under the influence of alcohol or drugs. This consent form is freely and voluntarily executed and shall be binding upon my spouse, relatives, legal representatives, heirs, administrators, successors and assigns.

I agree, if I should have any questions or concerns regarding my treatment / results I will notify this office at immediately so that timely follow-up and intervention can be provided.