Acroma QS Laser Consent Form (View Only)
Product/Treatment Information:
The Acroma QS laser is an FDA-cleared treatment designed to reduce and manage the pigmentary skin condition known as Melasma. The treatment may also enhance skin tone, target under-eye skin, and address pigmented keratosis and dark tattoos.
The Acroma QS is a Q-Switched laser that directs low-level laser light and acoustic energy into the skin where the dysfunctional melanocytes (Pigment-producing cells) are located. This energy passes through the skin's outer surface, called the epidermis, and penetrates the lower layers of pigmented skin cells. Rapid energy transfer from the laser light fractures the melanin (pigment within the skin cell), which is then ready to be excreted by the body.
You must be aware that you may require multiple treatments (as many as 2-10, depending upon the presenting condition). The final result can vary from person to person, depending upon your indication, degree of pigmentation, skin quality, and the degree of correction required.
Before Treatment:
Before beginning an Acroma QS laser treatment, you must first attend an assessment and information consultation with one of our Nurses or Aestheticians, during which your skin type, skin condition, expectations and goals will be assessed and discussed.
Your Practitioner will also provide you with the estimated cost of each session or series of sessions during this time. If you are a qualified candidate, you must undertake several patch tests of treatment in the indicated area at varying intensity levels. A patch test lets your practitioner understand how responsive your skin is and ensures a safe treatment is delivered. However, as detailed in this consent form, a patch test itself may result in unwanted side effects.
You must not have tanned skin or artificial tanning products on the treatment areas for four weeks before an Acroma QS laser treatment. Failure to comply with this could result in serious harm. If you have any doubt, do not have a treatment. You may still be charged if you tell us this less than 24 hours before your appointment.
Avoid all acid-based skin products, retinol and retinoids in the intended treatment area for three days before the Acroma QS laser
If you are prone to cold sores and your treatment is on your face, discuss prophylactic Aciclorvir medication with your GP or pharmacist. Acroma QS laser treatments can stimulate an outbreak in people who carry the cold sore virus.
Treatment:
Acroma QS laser treatments are virtually pain-free and do not require any anaesthesia. During the procedure, your practitioner will assess your comfort levels and adjust the treatment parameters where required. Please always communicate with your practitioner if you experience discomfort during treatment.
You will be required to wear protective eye covers throughout your treatment. Failure to do so or to follow practitioner safety instructions could result in physical harm or eye damage.
Your practitioner will cleanse the skin in the area requiring treatment. It is entirely possible to have an allergic reaction to any of the cosmetic products we use or apply to your skin. Please inform your practitioner immediately if you feel this is the case.
The Acroma QS laser will then be passed several times across the skin, gradually building a very mild pink colour to the skin. Frosting (white patches) may be seen on solar keratosis removal.
Aftercare calming skin products and sun protection cream will be applied to your skin before you leave. It is entirely possible to have an allergic reaction to any of the cosmetic products we use or apply to your skin. Please inform your practitioner immediately if you feel this is the case.
Post Treatment:
We want you to have the best treatment outcomes in the safest possible way. Any patient with a history of Melsama or post-inflammatory hyperpigmentation must purchase and use a prescription of products from the Nurse Prescriber in order to receive an Acroma QS treatment. Your practitioner will discuss which products will most suit your skin type and condition.
You must apply daily sun protection with UVA/UVB filters and an SPF of at least 30 to the treatment area, even on cloudy days. It is a condition of the treatments you receive with us that you commit to using this every day and avoiding sun exposure, artificial sun beds, and artificial tanning products in the treatment areas.
It is entirely normal for any pigmentation to become temporarily darker following Acroma QS treatment. It signifies that the pigmented cells are working up and out of the skin.
You may notice a tingle, mild heat sensation, and pink colour to the skin after an Acroma QS treatment, which is considered normal. These effects will usually settle on the same day.
Solar keratosis treatments may leave swelling and scabbing in the treatment area for around five days. This is normal and expected. It is essential you do not pick the area.
If you have concerns following an Acroma QS laser treatment, you must immediately contact your practitioner. You may require medical intervention from one of our clinic nurses.
Alternative Treatments:
Your practitioner will always advise you of the safest and most effective treatment based on your medical history and skin appearance. However, you should also consider the option of no treatment at all. Alternatively, other treatment options are available and include clinical skincare, chemical peels, and prescription medications. Please discuss these options with your practitioner if you wish to explore alternative options.
Contraindications:
You cannot have Acroma QS laser treatments if:
You have tanned skin either from UV light exposure or artificial skin tanning products. (No UV-tanned skin for four weeks before treatment).
You have or have a history of malignant (cancerous) skin lesions.
You have had roaccutane/Isotretinoin oral medication in the last six months.
You take photosensitising medications.
You apply photo-sensitising skincare and have not stopped for three days.
You have allergies or intolerance of lidocaine anaesthetic cream (Only if wanting the area numbed before treatment).
You have photosensitive epilepsy.
You have an active infection or inflammation near the intended treatment area, including active acne lesions.
You have open wounds in the intended treatment area.
You have an active outbreak of herpes simplex infection (Cold sores) in the treatment area.
You have a history of keloid or raised scarring.
You have uncontrolled diabetes or poor wound healing.
You have blood clotting problems or are taking blood thinning medications.
You are immunosuppressed.
You have uncontrolled hormonal disorders.
You have a pacemaker.
You have had facial fillers or botox in the intended treatment area under two weeks before treatment.
You think you could be pregnant, are pregnant, or are lactating/ breastfeeding.
Cautions:
You need to tell your aesthetic practitioner if:
You suffer from recurrent herpes simplex infections (cold sores). An Acroma QS laser treatment may encourage an outbreak.
You use topical retinol or retinoid prescription medications in the treatment area. You MUST stop using these on the treatment area three days before an Acroma QS laser treatment.
Material Risk (the level of significance you personally apply to the risks, side effects or complications of this treatment within your own circumstances):
As with any medical procedure, this treatment carries the risk of side effects or complications. Discuss these risks with your practitioner to fully comprehend their implications. Consider the risks in relation to your personal circumstances, including your health, lifestyle and career and decide if they are acceptable. If not, discuss alternatives or take more time to decide.
Associated Risks:
Discomfort. Acroma QS treatments are generally well tolerated with minimal discomfort; however, we encourage you to discuss this with your practitioner if you experience discomfort you cannot tolerate.
Skin erythema (skin redness) and heat. This is the most common and likely side effect of your Acroma QS laser treatment. This is related to the rise of internal skin temperature, which is normal. This can be managed by keeping the skin cool following your treatment. Heat sensation should subside within a few hours; however, it can last longer. Skin erythema will most likely only last a few days after the treatment.
Swelling, tingling, or tenderness. For a few days after treatment, you may experience slight discomfort (like mild sunburn) and swelling within the skin.
Pigment changes. With the laser energy used in Etherea MX Acroma QS treatments, there is a small risk of temporary hyperpigmentation (increased pigment or brown discolouration) or hypopigmentation (whitening the skin). Usually, these pigment effects are temporary and resolve over several weeks or months. Permanent hyperpigmentation or hypopigmentation is very rare and may occur in less than one per cent of cases. Using advised skincare products throughout the treatment course will reduce this risk. These medical skin care products are essential to obtain optimal results and reduce complications.
Skin wounds. Rarely, Acroma QS treatments may result in blisters or skin wounds, however if you have had a solar keratosis treatment, it is a normal response to reduce the pigmented tissue. If a blister or skin wound develops, it may take 5 to 10 days to heal and, in extremely rare instances, may lead to a noticeable whitening or darkening of the skin or, even more rarely, a scar. Blisters or skin wounds are much more common if you do not follow the recommended avoidance of sunlight, artificial tanning products, UV light exposure, and fluorescent light exposure pre and post-treatment.
Scarring. Very rarely, if you have developed a wound and a scar, the scar may become flat and white (hypotrophic) or large and red (hypertrophic), or it may extend beyond the margins of the injury (keloid). Subsequent treatment or surgery may be required to improve the appearance of the scar. In some cases, the scar may be permanent. Failure to follow pre- and post-treatment care instructions may increase the likelihood of a skin wound or scar.
Infection. Infection is exceedingly rare. However, a blister or wound formed due to Acroma QS treatments may become infected. To avoid infection, it is essential to contact your practitioner if you ever experience a blister or wound following your treatment.
Herpes (cold sores) reactivation. Treatments that create a skin injury, such as laser treatment, carry the risk of an outbreak of herpes (fever blisters/cold sores/shingles) in individuals who already carry the herpes virus. If the Acroma QS laser treatment is on your face and you are prone to cold sores, you should manage this as you would typically, such as using over-the-counter cold sore medication. If you experience these regularly, you may need a prescription for aciclorvir medication from your GP to suppress the virus before and after treatments. Please contact your practitioner if you experience a severe outbreak following treatment, as you may require a prescription from one of our Nurse Practitioners.
Dissatisfaction. Not all skin conditions and types are the same and may not respond as expected. Your skin’s response may be subject to variation. Although the overwhelming majority of patients who have undergone an Acroma QS laser treatment for Melasma reduction report a near-complete clearance of pigment, there is always a possibility that you may not see an appreciable reduction of melasma pigmentation or may have pigmentation that returns. We will always try our best to help you achieve your expectations; however, you must be aware that, even in these circumstances, we will not refund the treatment.
This consent form is not meant to include all possible risks associated with an Acroma QS treatment, as there are both known and unknown side effects and complications associated with any medical treatment. We have written this consent form to ensure you are fully informed of the procedure, the reasons why you may not be able to receive treatment, and the known risks of an Acroma QS treatment.
Photographs:
We need to take photos of the treatment area to document the original condition before treatment begins and to monitor results and potential changes throughout the treatment process. These photos will become part of your medical aesthetic treatment record at Lumiere Medispa.
You have the right to refuse consent for these photographs. However, please be aware that without this consent, we will not be able to treat you for medico-legal reasons.
If we wish to use your photos for any other purpose, we will always seek separate written consent from you. You have the right to refuse this additional use of your photos, and it is not mandatory to consent to any other photo usage to receive treatment.
By signing this consent form, you acknowledge and confirm the following:
Risks and complications
You have discussed the potential risks and benefits of an Acroma QS treatment with your practitioner, and your questions have been answered satisfactorily.
You understand that medical attention may be required to resolve any complications associated with your treatment. In most cases, except those in an emergency, you should contact your practitioner for advice/treatment.
Medical History
To the best of your knowledge, you have provided the details of your past medical history and will inform your practitioner if this changes before any future treatments.
You understand that withholding aspects of your medical history could lead to serious physical and mental harm.
Contraindications & Cautions
You are not pregnant or possibly pregnant, lactating or nursing, and you will inform your practitioner if this changes before any future treatments.
Fees & Charges
You understand and agree that all services rendered will be charged directly to you, and you are personally responsible for payment.
You further agree, in the event of non-payment, to bear the cost of collection, court costs and reasonable legal fees, should they be required.
Refunds
Fees charged for treatment are for the delivery of a treatment and the accompanying service, which is inclusive of the following;
-Consultation and assessment
-The provision of information and advice
-The provision of the treatment itself, as described above
-Follow-up appointments and aftercare advice and support as appropriate
Whilst we undertake to provide excellent service, factual, honest, and ethical advice, safe, expert treatment in experienced hands, and the best products, we cannot guarantee your results. We cannot offer refunds if the results achieved fail to meet your expectations. The successful outcome varies by degree, and how long these effects last varies from one individual to another and cannot be guaranteed.
You understand that whilst you have been advised of a probable result, this should not be interpreted as a guarantee.
You will contact your practitioner if you are dissatisfied with your treatment outcomes.
Aftercare
You have verbally discussed the aftercare required following an Acroma QS treatment and have been informed that you will also receive this via email. You understand the importance of following the post-treatment advice and agree to follow it.
You understand that failure to follow this advice could lead to serious physical and mental harm.
Photograph Use Consent
You understand that receiving treatment at Lumiere Medispa requires photographs to be taken of the treatment area. These photographs may be taken before, during, and after each treatment and will form part of your legal medical record at Lumiere Medispa. By signing below, you freely give your consent for your photos to be used solely for this medico-legal purpose. If we wish to use your photos for any other purpose, we will always seek separate written consent from you, and you have the right to refuse.
Valid Consent
By signing below, you acknowledge that you have read and understood this consent form in written English and have had the opportunity to discuss any questions you have with your practitioner to your satisfaction. You consent to receive an Acroma QS treatment under the terms of this consent form and understand that you have the right not to consent to this treatment and that your consent is voluntary.
