CONSENT FOR LASER HAIR REMOVAL I authorize Northridge Dermatology Associates, Inc. to perform laser hair removal on me. Treatment will be performed by Drs. Friedman or Coleman or by trained staff under the direction of Drs. Friedman and Coleman. I understand that the procedure is purely elective and the only indication is my request for treatment. I understand that insurance will not cover the procedure. For the best results, I understand that multiple treatments will be necessary and these will incur additional costs. Serious complications are rare, but possible. Common side effects include temporary redness and mild "sunburn" like effects lasting a few hours to 3-4 days (5-20% of patients). Pigment changes (light or dark spots on the skin) lasting 1-6 months may occur in 5-20% of patients and are most likely in darker skin types and especially in patients with tanned skin. (We do not recommend treatment of tanned skin). Other potential risks include itching, pain, bruising, burns, infection, scarring, swelling, and failure to achieve the desired hair loss. Lasers can cause eye injury and protective eyeware must be worn during treatment. I consent to photographs being taken during the course of my laser therapy to evaluate treatment effectiveness and for medical education. Before and after treatment instructions have been discussed with me. The procedure as well as potential benefits and risks have been explained to my satisfaction. I have had all my questions answered. I freely consent to the proposed treatment and guarantee to make payment as agreed. Name______________________________ Signature___________________________ Date___________ Witness________________________________ |
| Northridge Dermatology Associates David H. Friedman, M.D. William R. Coleman, M.D. 9535 Reseda Blvd., #304 Northridge, CA 91324 1-818-886-3884 |