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Halo Hybrid Fractional Laser Consent Form

I authorize a Master Esthetician to perform a Halo Pro fractional laser treatment on the following area(s) of my body: Select Areas

Face

Neck

Chest

Face & Neck

Face, Neck, Chest

Hands

Arms

Legs

Stomach

The Halo Pro Fractional Laser treatment uses hybrid technology of 1470 nm non-ablative laser and 2940 nm ablative laser to create controlled zones of coagulation to chosen depths into the dermis that stimulate neocollagenesi (new collagen) and fractionally vaporize (ablate) micro laser channels in the epidermis addressing tone and texture of the skin.

Review of facts about light therapy

The 2940 nm Erbium YAG laser wavelength of Halo Pro is delivered through a focused scanning device that precisely removes channels of tissue by vaporizing (heating to high temperature) the water within tissue. The device has the ability to create micro channels while leaving the area around the channels intact.
The 1470 nm laser wavelength of Halo is delivered through a scanning device that creates microscopic columns of wounded tissue that stimulates new collagen.
Laser treatment procedures may produce scanning patterns visible on the skin. This event usually fades while in the healing phase.
Light from a laser can be harmful to eyes and wearing special safety eyewear is necessary at all times during the procedure.
A topical or local (block) anesthetic is used to lessen the sensation of the laser as it interacts with the skin. The sensation, while being treated, may feel like pin pricks, bursts of heat or similar to a sunburn. The type of topical and or injected anesthetics is at the discretion of the practitioner. There are known severe allergic reactions to ingredients in topical anesthetics.

It is important that you read this information carefully and completely. Please initial this section indicating that you have read the section and sign the consent for this procedure as proposed by your master esthetician and agreed upon by you.

Pretreatment consideration

If you have previously suffered from facial cold sores, there is a risk that this treatment could contribute to a recurrence.

No one who has taken the medication Accutane or its generic forms within the last year may have this procedure.

No one on anti-coagulants may have this procedure.

Skin care or treatment programs may be used before and after laser skin treatments in order to enhance the results.

Treatment considerations

The procedure necessitates a post treatment wound care regime that must be followed.
The Halo Pro fractional laser treatment may produce pinpoint bleeding in the area of the channels. This event usually subsides in a few minutes to a few hours. More uncommon, it can persist up to 24 hours.
Redness and exfoliation (flaking of skin) is associated with this procedure and may last from 4-7 days or longer depending on the depth and concentration (percentage) of the laser channels of the treatment performed. You may notice a sandpaper texture and bronzing of the skin as the microscopic columns begin to heal. This is treated tissue working its way out as new skin is regenerated. Keeping the area moist with a light application of an occlusive barrier e.g. Alastin Skin Nector will aid in the healing process.

Common side effects and risks - PLEASE CHECK ALL BOXES BELOW

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Edema (swelling) of the skin may occur and can be minimized by keeping the area upright, and taking antihistamines.
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Urticaria (itching) often times occurs as the old skin is shed and the new skin is being formed.
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If any of the above symptoms intensify, your clinician should be notified. A cool compress placed on the area provides comfort. The treated area should be cared for delicately. Limited activity may be advised, as well as, no hot tub, steam, sauna, or shower use.
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Discomfort, especially a sunburn feeling, may persist for a few days.
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PIH or post inflammatory hyperpigmentation (browning) and hypopigmentation (lightening) have been noted with laser procedures. These conditions usually resolve within 2-6 months. Permanent color change is a rare risk. Vigilant care must be taken to avoid sun exposure (tanning beds included) before and after the treatment to reduce the risk of color change. After the skin has gone through its healing phase and is intact, sunscreen and / or sun block should be applied when sun exposure is necessary.
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Infection is not usual after treatments; however herpes simplex virus infections around the mouth can occur following treatments. This applies to both individuals with a past history of the virus or individuals with no known history. Other signs of an infection can be a fever, purulent (pus) material, severe redness, swelling in the area, and skin that is hot to the touch. Should these symptoms occur, the clinician must be notified to prescribe appropriate medical care.
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Allergic reaction is uncommon from Some persons may have a hive-like appearance in the treated area. Some persons have localized reactions to cosmetics or topical preparations. Systemic reactions are rare.
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The potential risks and benefits have been explained of the Halo Pro fractional laser treatment along with alternative methods. I choose to haveHalo Pro fractional treatment.
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I understand that compliance with pre and post care instructions is crucial for success of Halo Pro fractional laser treatment and to prevent unnecessary side effects or complications.
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I understand that there are many variable conditions which influence the long-term result of laser skin treatments. The practice of medicine and surgery and the subsequent use of laser is not an exact science. Although good results are expected, there is no guarantee, expressed or implied, on the results that may be obtained.
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I understand that the Halo Pro fractional laser treatment involves payment and the fee structure has been explained to me.

Photography

In order to track our progress, we at Skinlogic Med Spa like to incorporate the use of photos. It helps us to thoroughly see the changes in your body from beginning to end. Photos are to be used for documentation purpose, & if consented as advertisement for the product, and/or service etc.
Please initial one or all of the following:

Check if Applicable
Medical Care Only: Photographs taken of me or parts of my body can be used solely for the purpose of my medical care with Skinlogic Med Spa. The photographs and all details regarding medical services rendered to me will be kept confidential within my personal medical history file at Skinlogic Med Spa.
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Internet: Photographs taken of me or parts of my body as well as details regarding esthetic & medical services that I have received at Skinlogic Med Spa, can be used on the company’s website and social media in order to inform the public about esthetic and medical services. I give my consent as a voluntary contribution in the interest of public education, and my consent is subject only to the condition that I am not identified by name or any other identifying marks at any time during any use or publication of these materials by any party. Further, I release and discharge Skinlogic Med Spa and any of its employees and all parties acting under their license and authority, from any and all claims or actions that I have or may have relating to such use and publication.
Check if Applicable
All Media: Photographs taken of me or parts of my body as well as details regarding esthetic and medical services that I have received at Skinlogic Med Spa., can be used in any print or broadcast media, including, but not necessarily limited to newspapers, pamphlets, social media, educational films, internet, and television, in order to inform the public about esthetic and medical spa methods.I give my consent as a voluntary contribution in the interest of public education, and my consent is subject only to the condition that I am not identified by name or any other identifying marks at any time during any use or publication of these materials by any party.I do or do not consent to photographs and other audio-visual and graphic materials before, during, and after the course of my therapy to be used for medical, marketing, and education purposes. Although the photographs or accompanying material will not contain my name or any other identifying information, I am aware that I may or may not be identified by the photos.

Additional Treatment or Surgery Necessary - There are many variable conditions which influence the long-term result of laser skin treatments. Even though risks and complications occur infrequently, the risks cited are the ones that are particularly associated with these procedures. Other complications and risks can occur but are even more uncommon. Should complications occur, procedures, surgery or other treatments may be necessary. The practice of medicine and surgery is not an exact science. Although good results are expected, there is no guarantee or warranty expressed or implied on the results that may be obtained. I have read and understand all information presented to me before signing this consent form. I have been given an opportunity to have all of my questions answered to my satisfaction. I understand the procedure and accept the risks. I agree to the terms of this agreement.

I CONSENT TO THE HALO TREATMENT AND I HAVE READ THE ABOVE LISTED ITEMS. I AM SATISFIED WITH THE INFORMED CONSENT PROCESS

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March 9, 2025 2:38 pm PDT

Halo Hybrid Fractional Laser Consent Form Uploaded by scott smith - scottsm8@gmail.com IP 98.203.141.236