Healthcare Erbium Treatment Form

HEALTHCARE ERBIUM TREATMENT FORM

Patient Information

Patient Name:    Date of Birth:    Gender:

Insurance (if applicable)

Provider:    Policy #:    Group #:

Medical History

Have you taken isotretinoin (Accutane) in the past 12 months? Yes    Do you have a history of abnormal scarring or keloids? Yes

Do you have any active skin infections, open wounds, or recent cold sores in the treatment area? Yes

Proposed Procedure

Procedure: Erbium YAG laser skin resurfacing / ablative treatment for indicated areas including:

Intended benefit:

Risks, Benefits, and Alternatives

I acknowledge that the provider has explained the nature of Erbium laser resurfacing, expected benefits, likelihood of success, and reasonable alternatives including no treatment, topical therapies, chemical peels, and other laser modalities. I understand that results cannot be guaranteed.

Significant risks and potential complications include but are not limited to: prolonged redness, hypopigmentation, hyperpigmentation, scarring, infection, textural irregularity, recurrence of acneiform eruptions, delayed healing, and allergic reactions. I understand that some risks may be permanent.

Specific risks checked and initialed by patient to acknowledge discussion:

Prolonged redness and swelling    Pigment changes (lightening or darkening)

Scarring    Infection

Preparation and Aftercare

Pre-treatment instructions provided and understood: avoid tanning, stop topical retinoids for 3–7 days unless directed otherwise, avoid anticoagulants or NSAIDs as instructed by provider, and disclose all medications. I agree to follow pre-procedure skin prep and arrive with clean skin.

Post-treatment care will include wound care, use of recommended ointments, sun avoidance, and follow-up visits. I understand failure to comply with aftercare instructions may increase risk of adverse outcomes.

Photography and Records

I consent to clinical photographs for treatment planning and medical record documentation. Photographs may be used for educational or quality assurance purposes without identifying information unless separate written consent for promotional use is obtained.

I consent to photography for medical record and quality assurance.    I consent to anonymized educational use only (no patient identifiers).

HIPAA / Privacy Acknowledgment

I acknowledge that I have received or been offered the facility’s Notice of Privacy Practices describing how my protected health information may be used and disclosed. I authorize the release of my health information necessary for treatment, payment (if applicable), and healthcare operations as described in that notice.

I acknowledge receipt of the Notice of Privacy Practices.

Authorization and Release

I authorize the provider and staff to perform Erbium laser resurfacing as described above. I certify that I have provided a complete and accurate medical history and have had the opportunity to ask questions about the procedure, risks, benefits, and alternatives. I understand that results cannot be guaranteed and that unforeseen conditions may require additional procedures.

I release the provider and facility from liability for complications resulting from this procedure, except in cases of gross negligence or willful misconduct. I agree to follow all pre- and post-procedure instructions and attend follow-up appointments as recommended.

Additional Consents

I consent to topical or local anesthetic agents as indicated. I understand that allergic reactions are possible and have disclosed relevant allergies.

Consent to topical/local anesthetic as needed

Patient Affirmation

By signing below I affirm that I have read and understand the above information, that my questions have been answered to my satisfaction, and that I consent to the proposed Erbium laser treatment. I understand I may withdraw consent at any time prior to the procedure.

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