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Laser   Information & Consent Form

 

I consent to Dr Larissa Miller using the laser for treating  vascular lesions – such as “broken” capillaries and spider lesions – on my  face/body/legs. 

 

I certify that I have been informed about the procedure  and the prospects of success and have had the opportunity  to ask further questions.

 

I understand that no guarantee or assurance has been made as to the results of the procedure and that it may not cure the condition even with multiple treatments.

 

I understand that there are certain risks involved in using the above laser:

 

The main side effect of the laser treatment is pain during the treatment and for 15 minutes after (but sometimes longer). The treated area will then become flushed like a mild sunburn but will settle in a few hours.

 

Less commonly the area may be lightly burned like a sunburn with redness a light crust and peeling over the next 3 days. This will usually take no more than 1 week to settle.

 

Local pigmentation reactions, with either lightening or darkening of skin are uncommon. If they occur they are usually temporary, recovering over several months.

 

Rare side effects are permanent pigmentation changes and altered skin texture or scarring. These side effects are more likely if skin infection  occurs due to picking at the treated area.

 

I understand that the practice of medicine and surgery is not an exact science, and that therefore reputable practitioners cannot properly guarantee results. I acknowledge that no guarantee or assurance has been made by anyone regarding the procedure which I have requested and authorised.

 

I hereby consent to treatment as outlined above. I also consent to the taking of photographs for the medical record and further consent to their use for research, teaching or publication, with the understanding that I will not be identified or identifiable from such photos.

 

If I claim a rebate from Medicare that I certify that the vessels were visible from 4 metres  and the treatment took 20 minutes.

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Patient’s name                         Signature (patient or guardian)                       Date

 

I certify that I have made the disclosures referred to above to the patient and that he/she has been invited to ask questions.

 

 

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Dr Larissa Miller                          Date

 

 

 

 

 

 

 

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CONTACT

 

Email: vistaclinicau@gmail.com

Phone: +61 (0) 408 875 490

Fax: +61 (03) 9978 9484

Business Hours: Tue, Fri 9am - 7 pm, Sunday 9am-12pm 

*additional time by appointment available for regular patients

Address: 4/433, South Road, Bentleigh 3204 VIC Australia