Dr Lanzer - Consent form for Laser Resurfacing 1. I ____________________________, request Dr Lanzer to perform the procedure called Laser Resurfacing. The procedure has been explained to me by Dr Lanzer in detail and I have read all the attached information sheets. 2. It has been explained to me that for 5-7 days, I will have dressings on my skin and healing will take place between 7-10 days. After this time I have been informed that my skin may be red for a few weeks and rarely for 6-12 months. This should be coverable with make-up creams. 3. I have also had other alternatives explained to me which include collagen injections for wrinkles, chemical peels, dermabrasion and face lift surgery. 4. I undertake to avoid sun exposure strictly for three months and generally be careful with the sun for six months. eg.: Apply make-up and sunblock preparations. 5. I am aware that procedures such as laser resurfacing, although rare, do have risks. In particular I have been informed of the risk of scarring which may appear as persistent red, thickened areas or less likely, red scars that protrude from the skin. I am also aware that there may be pigmentation problems which include brown pigmentation or white depigmentation. I am aware that a lot of these problems can be treated and I give permission for intervention if required. 6. Other rare risks that have been explained to me include the development of red blood vessels, small white milial cysts, persistent redness, infection and pain or irritation after the procedure. 7. Very rarely, tightening or scarring of the lower eyelid skin could pull the eyelid downward (ectropion). 8. I agree to have photographs before and after the surgery and give permission for them to be used by Dr Lanzer for medical, research and educational purposes. 9. I also undertake not to do anything to my skin other than what has been explained to me by Dr Lanzer. 10. I am aware that as with all surgery, cosmetic surgery is a serious procedure involving risks and that it should not be rushed into or undertaken lightly or without proper consultation including a discussion of the risks and alternatives which I have received from Dr Lanzer and his staff. 11. I am aware that surgery is not an exact science and involves healing of the body which varies between patients. Therefore, no guarantees of the amount of cosmetic improvement can be given. No promises or representations have been made to myself, either orally or in writing by Dr Lanzer or his staff as to a particular outcome or as to the result or permanency of this procedure. 12. I understand that I cannot expect a 100% perfection and that repeat localised laser resurfacing may be required for very deep wrinkles or acne scars.
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