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This form is designed to give you the information you require to make an informed choice of whether or not to undergo treatment with LUMECCA™ technology.
• I hereby authorize Lotus by MDs @ Queensway associates to perform the LUMECCA Intense Pulsed Light (IPL) Treatment.
• The physician obtained my medical history and found me eligible for treatment.
• I have received the following information about the technology:
o LUMECCA™ is a non-invasive technology that utilizes Intense Pulsed light for Skin Rejuvenation and Pigmented and Vascular lesions improvement.
o Pigmented lesions will become darker over a period of 1-2 weeks before starting to lighten. Local inflammation around the lesions, manifested as some redness and swelling may accompany the response and is a part of the healing process.
o Blood capillaries will clot and appear darker for 1-2 weeks before disintegration. Some redness and swelling may accompany the response, as part of the healing process.
o Some skin tightening may occur immediately. New collagen production will continue for up to 2 months after the procedure.
o Complete clearance of pigmented and vascular lesions is not guaranteed.
o Treatment requires 2-5 sessions based on individual assessment and response to treatment.
o There may be some discomfort associated with treatment.
o There is a small risk of adverse reactions such as scabbing, bruising or blistering.
• I understand that taking the treatment course is my choice and that I am free to withdraw at any time, without giving any reason.
• I was told about the possible side effects of the treatment including local discomfort, skin redness (erythema), swelling (edema), damage to the natural skin texture (crust, blister, burn), change of pigmentation (hyper- or hypo-pigmentation), and scarring. Although these effects are rare and expected to be temporary, any adverse reaction should be reported immediately.
• I understand that I must comply with treatment schedule, otherwise results may be compromised.
• I recognize that during the procedure unforeseen conditions may necessitate different procedures than this above and I authorize the physician or associates to perform such other procedures if they find them professionally recommended or necessary.
• I understand that not everyone is a candidate for this treatment and results may vary, therefore, there is no guarantee as to the results that may be obtained.
• Lumecca Photofacial (IPL) Patient Instructions copy has been provided to me and I understand recommended Pre-procedure and Post-Procedure Care.
• Any questions I may have asked have been answered to my satisfaction.
