Informed Consent Form For Facial Depigmentation Treatment Cosmelan

am interested in receiving the COSMELAN treatment.

I DECLARE that the following points have been explained to me:

Has explained the advantages and possible initial side effects when undergoing a cosmelan  depigmentation treatment.  Initial ___

The purpose of this technique is to remove the most superficial layers of the skin in order to  stimulate cell renewal and as a final result, to obtain an even cutaneous tone and / or the  elimination of hyperpigmentation. Initial ___

The treatment consists of the elimination of the outermost layers of the skin by the application of  chemical agents, to create a superficial burn and subsequent re-epithelialisation. Initial ___

It has been explained to me by the clinician / therapist that in order to obtain best results, I must strictly follow the mesoestetic home care protocol for a minimum of 6 months. No other skincare  brands are to be used during this time. Initial ___

I understand that some side effects can appear such as swelling, pain, high sensitivity, itching,  scaling, superficial desquamation, erythema, acne or herpes simplex breakout, hyper or hypo  pigmentation of the area treated. The downtime can last around five days but can vary from  patient to patient.  

Initial ___

The clinician / therapist has warned me to avoid direct sun exposure after each session and I  understand the high importance of following the homecare protocol which includes sun  protection, after the treatment.  Initial ___

The clinician / therapist has provided and explained to me the home maintenance protocol. Initial ___

I have been informed that the final result depends upon strictly following the home maintenance  protocol, for a minimum of six months. Initial ___

I understand that due to the nature of the treatment individual results may vary and cannot be  guaranteed, and in very rare cases there may not be a visible result at all. Initial ___

My medical history is important to determine the success of the treatment. Initial ___

It is imperative to check for the following: Contraindications: (tick to confirm not applicable) 

• Sunburn (avoid exposure to UV radiation for 15 days before treatment) 

• Pregnancy and breastfeeding 

• Skin diseases, allergies to any of the components of the formulation 

• Treatment with isotretinoin, antibiotics, hydroquinone. 

• Autoimmune disorders e.g. Diabetes, Lupus, HIV, Hepatitis, Crohn’s disease 

• Dermatological disease (psoriasis, eczema) 

• Cancer / Skin Cancer / Cancer Remission 

• Chemotherapy 

• Active acne 

• Bacterial, viral, fungal or herpes infection  

• Family or personal history of keloid scarring 

• Vitiligo 

• Aspirin allergy  

• Rosacea  

• Laser / IPL / Waxing in the last 2-4 weeks (in the treatment area)

Precautions: (tick to confirm if applicable) 

• Thyroid 

• Multiple Sclerosis 

IMPORTANT: If in doubt, seek medical advice and/or permission from medical specialist

We have decided that cosmelan is the most convenient treatment for my particular case, although other  alternatives are possible. My clinician / therapist has discussed these alternatives. Initial ___

The cosmelan procedure has been explained to me. My questions regarding the treatment, its  alternatives, its complications and risks have been answered by the clinician / therapist, or by written  information. Initial ___

I understand all the information given to me. I understand the risks and initial side effects as well as the  downtime of the treatment. Initial ___

My questions have been fully and completely answered. I have read this document and understand its  contents. Initial ___

I give my permission to take photographs of all treated sites for diagnostic purposes and to accurately  document the treatment in the usual and customary manner. I agree that these photographs are the  property of the clinic. Initial ___

I will not make any claims or complaints either to the business owners, the employees or the  manufacturer. Initial ___

I hereby give my unrestricted informed consent to perform the facial depigmentation cosmelan  procedure.

I GIVE MY CONSENT to receive the COSMELAN TREATMENT by mesoestetic®.