Eclipse Laser Peel Consent Form

Treatment Information

The Eclipse Laser Peel treatment exfoliates the skin, drawing out impurities and stimulating collagen production. A carbon mask is applied to the skin, absorbing excess sebum and sticking to dead skin cells. Using the Acroma QS, a low-fluence Nd: YAG Q- Switch 1064nm laser, the carbon absorbs the light, rapidly converting to energy and fracturing the carbon particles. This rapid evaporation of carbon particles removes the excess sebum and dead skin cells from the surface. The heat stimulates a mild wound-healing process that prompts collagen formation, improving pore appearance and softening fine lines. Combined with LED phototherapy, it leaves the skin glowing and soothed.

There is little to no downtime to this treatment. There may be a slight tingle sensation with some warmth, but the treatment is considered by most patients as comfortable. Mild erythema (pink skin) may be present for a few hours.

This treatment can be used as part of a treatment plan (initially three treatments, two weeks apart, then once a month) or as a sporadic standalone skin brightening and decongesting treatment.

Before Treatment

Before beginning an Eclipse 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, a patch test itself may result in unwanted side effects, as detailed in this consent form.

Avoid all acid-based skin products, retinol and retinoids in the intended treatment area for four days before this treatment.

If you are prone to cold sores, discuss prophylactic Aciclorvir medication with your GP or pharmacist, as Acroma QS laser treatments can stimulate an outbreak in people who carry the cold sore virus.

Treatment

The Eclipse Laser Peel is a multi-stage treatment that includes skin cleansing, acidic skin peeling, carbon paste application, Nd: YAG Q-Switched laser treatment, application of skin-brightening skincare products, and LED phototherapy.

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.

This treatment and the application of laser 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 the 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.

Post Treatment

We want you to have the best treatment outcomes in the safest possible way. For this reason, it is a condition of your treatment with us that you purchase and use a clinically validated sun protection product. 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.

Please note that any areas treated with the Acroma QS laser will leave your skin photosensitive and must be protected from UV light (sun or sunbeds) for at least two weeks following the treatment. Failure to follow this increases your risk of adverse effects, such as dyspigmentation.

It is entirely normal for any existing pigmentation to become temporarily darker following this treatment. It signifies that the pigmented skin cells are working up and out of the skin.

After this treatment, you may notice a tingle, mild heat sensation, and pink skin colour, which is considered normal. These effects will usually settle on the same day.

You must contact your practitioner immediately if you have any concerns following an Acroma QS Eclipse Laser Peel treatment. 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 to decongest and brighten the skin, such as skin peels, microneedling and skincare. The CellRenew Facial is a good alternative with minimal downtime, similar to the Carbon Laser Peel. Please discuss these options with your practitioner if you wish to explore alternative options.

You cannot have Acroma QS Eclipse Laser Peel treatments if:

You have or have a history of malignant (cancerous) skin lesions.
You have had roaccutane/Isotretinoin medication in the last six months.
You take photosensitising medications/apply photosensitising skincare.
You have any allergies to carbon, charcoal, fruit acids or any other ingredients applied within the procedure.
You have photosensitive epilepsy.
You have an active infection or inflammation nearby 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 lactating/ breastfeeding.

You need to tell your aesthetic practitioner if:

You suffer from recurrent herpes simplex infections (cold sores). An Eclipse Laser Peel 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 Eclipse Laser Peel.

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. 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 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. This should subside within a few hours but can last longer.
Swelling, tingling, or tenderness. For a few days after treatment, you may experience slight discomfort (like a mild sunburn) and mild swelling within the skin.
Allergy. Throughout the procedure, we use various topical skin products to loosen dead skin material, absorb light energy and have positive skin-brightening effects. You may have an allergic reaction, including anaphylaxis, to any topical product applied. This could range from red, itchy skin to swelling and blockage of the airways. This is very rare; however, it is important that you declare all known allergies to your practitioner. Please be aware you may have an allergy that you do not currently know of and may still have an allergic reaction. It is important that you contact the clinic as soon as possible if you feel you are experiencing an allergic reaction following your treatment.
Pigment changes. The laser energy used within the Eclipse Laser Peel carries 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, the treatment may result in blisters or skin wounds. 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 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. 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 receive the Eclipse Laser Peel treatment are happy with their results, there is always a possibility that you may not see an appreciable difference in your skin appearance. 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.

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.

Photographs:

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.

Informed Consent:

This consent form is not meant to include all possible risks associated with an Eclipse Laser Peel 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, reasons why you may not be able to receive treatment and known risks of an Eclipse Laser Peel 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 Eclipse Laser Peel 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 only 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 unsatisfied with your treatment outcomes.

Aftercare

You have verbally discussed the aftercare required following an Eclipse Laser Peel 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 and have had the opportunity to discuss any questions you have with your practitioner to your satisfaction. You consent to receive an Eclipse Laser Peel 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.