Xtremely Precise Light (XPL) Informed Consent Form
The next generation of Intense Pulsed Light (IPL)
Informed Consent. Before and After Care Instructions
Remove Age Spots and Red Discoloration from skin. Face, hands, chest & more!
Congratulations on scheduling your cosmetic procedure at Spa 35 Medical Spa.
Use the Information below to learn how to prepare for your treatment and how to maximize your experience after your procedure.
The informed consent form for each procedure also provides important information. Please be sure to read it before signing. Ask a Spa 35 team member to answer your questions before scheduling your procedure.
Call Spa 35 with any questions or concerns regarding your treatment at 208-367-0700. After business hours select option 4 for urgent after-hours assistance. If you have an emergency call 911.
IPL - Treatment Purpose
Xtremely Precise Light (XPL) is great for decreasing the appearance of age spots, freckles, irregular pigmentation, large pores, and brown and red discoloration. Common symptoms of sun exposure and the aging process. This quick treatment rejuvenates and revitalizes the skin, creating a more youthful appearance. XPL can be used effectively to destroy discolored tissues located in the skin with minimum damage to the surrounding tissues. XPL is used to lighten, fade or remove photo-damaged skin in a non-ablative manner, a procedure commonly known as photo rejuvenation. Multiple sessions are required for optimal results, treatments are usually delivered in a series of two to four treatments spaced about four weeks apart for optimal results. Annual touch-up treatments are usually beneficial for people with sun damaged skin.
IPL - Consent for Treatment
Informed consent documents are used to communicate information about the proposed cosmetic treatment along with disclosure of risks and alternative forms of treatment(s). Despite Intense Pulsed Light Therapy’s high levels of efficacy and safety, treatments not free of side effects. As a patient you have the right to be informed about your treatment so that you may make the decision whether to proceed with the Intense Pulsed Light treatment or decline after knowing the risks involved. This disclosure is to inform you about the risks, side effects and possible complications related to Intense Pulsed Light prior to your treatment. This disclosure should not be considered all-inclusive in defining other methods of care and risks encountered. Spa 35 may provide you with additional or different information which is based on all the facts in your particular case and the state of medical knowledge.
IPL - Risks
There are both risks, and complications associated with this light-based cosmetic procedure for the skin. Although the majority of patients do not experience these complications, you should understand the risks and potential complications of laser skin treatment.
Potential risks and experiences include, but are not limited to:
Burned skin- The light energy from an XPL treatment can burn your skin, in some cases severely. It is important to tell your provider about recent sun exposure and to report any use of light sensitizing drugs (such as Accutane) with an accurate medical history form. Dark skin has a greater probability of burning than lighter skin. Self-tanning lotions dramatically increase the risk of burns.
Scarring- The Intense Pulsed Light system can burn or blister the skin which creates a risk of scarring.
Photosensitizing medication complications- Some over the counter and prescription medications can increase the risk of burning. We are unable to treat clients that are on ACCUTANE, and PHOTOSENSITIZING medications.
Hyper-pigmentation (browning) and Hypo-pigmentation (whitening)- Both have been noted after treatment, especially with a darker complexion. This usually resolves within weeks but can take as long as 3-6 months. Permanent color change is a rare potential risk. If you have dark skin a skin lightening cream may be advised to reduce the melanin in your skin before the treatment. Avoiding sun exposure after the treatment reduces the risk of color change.
Viral Outbreaks- Herpes simplex virus outbreaks can be triggered around the mouth and vulva by an XPL treatment. This applies to both individuals with a past history of herpes simplex virus outbreaks and to those without previous outbreaks. If you have a history of herpes simplex virus in the treated area, we recommend preventative therapy with an oral anti-viral medication.
Infection- Although infection following pulsed light treatment is unusual, bacterial, fungal, and viral infections can occur with scabbing or other disruption of the skin barrier function. Should any type of skin infection occur, additional treatment including antibiotics might be necessary.
Diabetes- If you are diabetic, there are increased health risks and potential healing problems associated with many of our services. You may be asked to provide proof of a Hemoglobin A1C of 7.0 or lower prior to receiving any treatment.
Bleeding- Pinpoint bleeding is rare but can occur following brown spot and spider vein treatment procedures. Should bleeding occur, additional treatment might be necessary.
Skin tissue pathology- Energy directed the skin may potentially vaporize diseased lesions making laboratory examination of a tissue specimen impossible. If you have discolored skin that is potentially cancerous you should have it examined by a dermatologist or other medical provider before your XPL treatment.
Allergic reactions- In rare cases, local allergies to tape, preservatives used in cosmetics or topical preparations, have been reported. Systemic reactions (which are more serious) may result from prescription medicines. Your skin may be numbed using an analgesic agent(s). Analgesics typically include but are not limited to benzocaine, lidocaine, tetracaine and epinephrine. There is the possibility of complications, injury, and even death from all forms of analgesics. Allergic reactions may require additional treatment.
Breastfeeding- Women who are currently breastfeeding cannot use any analgesic agents (typically used for numbing the area prior to treatment). Analgesics and topical numbing creams have not been studied on breastfeeding women. There is a risk that those agents can be found in breast milk.
Eye Damage- Eye damage can occur from the XPL energy. Protective eyewear must be worn during the treatment.
Pacemaker or internal defibrillator damage- It is possible for an IPL treatment to interfere with functioning of a pacemaker or internal defibrillator.
Hair loss- There is a known and expected loss of hair in the treated areas. In a very small percent of people there is new hair growth in the surrounding areas being treated.
IPL - Pre Treatment Instructions
It is prudent to follow some simple guidelines before your treatment. These guidelines can reduce possible side effects associated with the procedure and make all the difference between a fair result and a great result.
Sun exposure- Avoid sun exposure and tanning beds for at least three weeks prior to your treatment. Your appointment will be rescheduled if needed.
Hydrate - Drink at least eight glasses of water per day to completely hydrate your skin.
Self-Tanner- Stop self-tanner for four weeks prior to treatment.
Skin Care- Stop exfoliating skin care products, such as retinols and glycolic acid, for one week before your treatment.
Over the Counter Medications- Avoid aspirin, Motrin, Ibuprofen and sun sensitizing medications for one week prior to your treatment. Inform your provider if you are taking blood thinners or regularly take aspirin or Ibuprofen.
Prescription Medications – Review prescription medications with your provider for potential sun sensitizing effects.
Accutane- Inform your provider if you have taken Accutane (oral acne medication) in the past year.
Supplements- Avoid fish oil, Gingko Biloba, Garlic, Flax Oil, Cod Liver Oil, Vitamin A, Vitamin E, or any other supplements one week before treatment.
Alcohol- Avoid alcohol for two days prior to treatment.
Ice Packs- Store ice packs in your freezer for use after you get home from procedure.
Special Events- Schedule your treatment at least three weeks prior to a special event i.e., wedding, vacation, speaking engagement, to allow time for the healing process.
Photographs- Take at home photos to monitor your skin improvement.
IPL - Treatment Day Instructions
Make-up- Please arrive for your appointment without make-up
Clothing- Wear comfortable clothing with an open collar.
IPL - Post Treatment Instructions
Most people tolerate the XPL treatment with little or no downtime. You may be red, irritated, swollen and splotchy after your treatment. Discolored skin may get darker before it is exfoliated. It can take 4-6 weeks after your XPL treatment series completion to see the complete results.
Darker brown spots- Brown spots and freckles may appear darker while healing from your XPL treatment, particularly after the first treatment in your series. Do not attempt to remove these discolored areas. Allow them to exfoliate from the skin naturally.
Redness and Swelling- The sessions are designed to provide minimal downtime however, you may find that your skin is puffy and red after treatment. Erythema (redness) and edema (swelling) of the treated area usually subsides within a few hours but can last up to seven days or longer. It is usually most pronounced immediately after the treatment and in the morning after your treatment. You may use cold compresses (5 minutes on and 10 minutes off) several times an hour to help ease both redness and swelling. Irritation, itching, and/or a mild burning sensation or pain similar to sunburn may occur within 48 hours of treatment.
Scabs- The skin treated can be red and swollen with fine, thin scabs forming. If your skin is burned it increases the risk of scaring. Please keep the treated areas well moisturized until the thin scabs fall off to decrease the risk of scaring. Do not scratch the scabs, which can cause scarring. This process will take anywhere from 1-3 weeks. It could take as long as 3-6 months in some cases.
Sleep elevated. Sleeping with your head elevated for the first night will also help decrease any swelling you may experience.
Blistering and crusting care- If you experience scabs or burn apply a thin layer of over-the-counter antibiotic ointment such as Polysporin® can be applied 2-3 times a day for 3 days. Please call us if you experience either burns or scabs.
Hyperpigmentation and hypopigmentation- (darkening or lightening of the skin color) can occur. Please call us if you experience this reaction.
Over the counter medications- Avoid Aspirin, Ibuprofen, alcohol, heavy exertion, and activities which may cause flushing for 2 days after treatment
Skincare- Your skin may be temperature sensitive for several days after treatment. Use mild cleansers and moisturizers. Avoid topical products such as retinols and glycolic acid products for at least one week after treatment.
Sun- Avoid direct sunlight on the treated area and use a broad-spectrum UVA/UVB sunscreen of SPF 30 or greater for 4 -6 weeks after your treatment.
Social Downtime- Anticipate some social downtime following your treatment.
IPL - Treatment Schedule
We recommend an initial series of 2-4 treatments spaced every 3-4 weeks. You may desire annual touch up treatments to manage dischromias caused by sun damage and aging.
IPL - Alternative Treatment Options
The Intense Pulsed Light procedure reduces darkly pigmented sunspots and spider veins. Alternative procedures include no treatment, chemical peels, CO2 laser resurfacing, Pixel resurfacing, Picoway Resolve treatment, Aminolevulenic Acid treatment, topical skin care (both non-prescription and prescription). More than one laser session may be necessary to achieve desired results. However, other treatments, including skin care products, are often needed to blend color, reduce sun damage, and give the best results. Risks and potential complications are associated with alternative forms of treatment that involve skin treatments or cosmetic procedures.
IPL - Synergistic Treatments
CO2 Laser Resurfacing – Tightens skin and reduces lines and rough texture
Frax 1550 Resurfacing – Stimulates collagen growth. Tightens skin, reduces lines.
Profound RF Tightening – Rebuilds strength and thickness of your dermis to tighten skin
Sublative RF Resurfacing - A radio frequency resurfacing procedure that is ideal for the area around the eyes and for people with darker skin complexion.
Chemical peels – A liquid or paste that changes your skin pH which causes exfoliation of epidermal cells.
Botox and Dysport – Decreases appearance of lines caused by muscle movement. Usually used around the eyes and in the upper face.
Dermal fillers – Replaces or enhances facial volume. Lips and cheeks are two common areas treated.
IPL - Acknowledgement
I have read and understand the Pre and Post Treatment Instructions. I agree to follow these instructions carefully. I understand that compliance with recommended pre and post procedure guidelines are crucial for healing, prevention of scarring, and other side effects and complications such as hyper pigmentation, hypo pigmentation, and other skin textural changes. Particularly the possible adverse effects of light sensitizing drugs, such as Accutane and those of anticoagulants.
I understand that this treatment is not meant to replace the necessity for a complete dermatological examination of suspicious lesions.
I confirm that I am not pregnant at this time, and that I have not taken Accutane within the last 6 months. I do not have a pacemaker or internal defibrillator. I also have completed an accurate medical history document and been informed about what I must do and "not do" before, during and after the series of treatments.
Photographs: I give permission for my photographs to be used to help document my treatment course. Complete confidentiality will be maintained.
No guarantee, warranty, or assurance has been made to me as to the results that may be obtained. I am aware that follow-up treatments may be necessary for desired results. Most patients require a number of treatments over several months with gradual results occurring over this time. Clinical results will vary per patient. Laser or other treatments may not completely improve or prevent future skin disorders, lesions, or wrinkles. Additional cosmetic procedures may be necessary to further tighten loose skin. I agree to adhere to all safety precautions and regulations during the treatment. Some people are unable to complete the treatment due to discomfort. No refunds will be given for treatments received.
I recognize that during the course of the treatment, medical treatment or anesthesia, unforeseen conditions may necessitate different procedures than those above. I therefore authorize Spa 35 providers to perform such other procedures that are in the exercise of his or her professional judgment necessary and desirable. The authority granted under this paragraph shall include all conditions that require treatment and are not known to the provider at the time the procedure is begun.
I understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment.
The nature and purpose of the treatment have been explained to me. I have read and understand this agreement. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement. Alternative methods of treatment and their risks and benefits have been explained to me and I understand that I have the right to refuse treatment.
If I experience any major or life-threatening symptoms, I will call 911 immediately. For non-emergency questions I will call Spa 35 at 208-367-0700, (for after-hours concerns selection option #4).
I release Spa 35, medical staff, and specific technicians from liability associated with this procedure. I certify that I am a competent adult of at least 18 years of age. This Consent Form is freely and voluntarily executed and shall be binding upon my spouse, relatives, legal representatives, heirs, administrators, successors, and assigns.
By signing below I consent to and authorize Spa 35 to perform this treatment(s) and to deliver any post treatment medical services that may be necessary.
Please contact the Spa 35 team if you have questions about IPL Skin Rejuvenation and/or the information on this page.
Why Chose Spa 35 Med Spa for Your Cosmetic Treatments?
The medical providers at Spa 35 Med Spa have been delivering cosmetic services for thirteen years. Our staff includes Nurse Practitioners, Registered Nurses and Aestheticians.
Experience - Spa 35 Med Spa has been helping clients Look and Feel their Best for twelve years.
Medical Staff - The team is led by Nurse Practitioners and composed of Registered Nurses and aesthetic skin care professionals. Botox and filler injections are performed by medically trained injectors, not estheticians.
Industry Leadership - Warren Danforth, the Spa 35 owner, is a Key Opinion Leader for Syneron-Candela's Medical Spa Program. Syneron-Candela is a global non-surgical aesthetic device company.
Broad Scope of Expertise - From Botox to CoolSculpting Fat Reduction and Vaginal Rejuvenation, Spa 35® Med Spa has an extensive set of experience to help you reach your goals. This means you get the expertise to help you select the service(s) are right for you and your budget.
Photographs on this website are used to illustrate how services are used and their potential impact on your appearance. Your results will not completely match any photographs. Genetics, sun exposure, diet and exercise all influence your results. The Spa 35 Med Spa team strongly encourages all of our clients to maximize their lifestyle choices.