Stacey Folk, MD, PC

www.folkplasticsurgery.com
303-321-6608

SCITON INFORMED CONSENT

INTRODUCTION

Lasers have been used by surgeons as a surgical instrument for many years. Laser energy can be used to cut,
vaporize, or selectively remove skin and deeper tissues. There are many different methods for the surgical use of
lasers.

Conditions such as wrinkles, sun damaged skin, scars and some types of skin lesions/disorders may be treated
with the laser. In some situations, laser treatments may be performed at the time of other surgical procedures.

Skin treatment programs, such as Obagi or Triluma, may be used both before and after laser skin treatments
in order to optimize the treatment and enhance the results.

Alternative Treatment – Alternative forms of treatment include not undergoing the proposed laser skin
treatment procedure. Other forms of skin treatment (chemical peel) or surgical procedures (dermabrasion or
excisional surgery) may be substituted. In certain situations, the laser may offer a specific therapeutic advantage
over other forms of treatment. Alternatively laser treatments procedures in some situations may not represent a
better alternative to other forms of treatment that involve skin treatments or surgical procedures.

Risks of Erbium: YAG Laser Treatment of Skin – There are both risks and complication associated with all
laser treatment procedures of the skin. Risks involve both items that specifically relate to the use of laser energy as
a form of surgical therapy and to the specific procedure performed. An individual’s choice to undergo a procedure
is based on the comparison of risk to potential benefits. Although the majority of patients do not experience these
complications, you should discuss each of them with our surgeon to make sure that you understand the risks,
potential complications and consequences of laser skin treatment.

Infection – Although infection following laser skin treatment is unusual – bacterial, fungal and viral infections
can occur. Herpes simplex virus infections around the mouth or other areas of the face can occur. This applies to
both individuals with a past history of Herpes simplex virus infections and individuals with no known history of
Herpes simplex virus infections in the mouth area. Specific medications such as Valtrex may be prescribed and
taken both prior to and following the laser treatment procedure in order to suppress an outbreak from this virus.
Should any type of skin infection occur, additional treatment including antibiotics may be necessary.

Scarring - Although normal healing after the procedure is expected, abnormal scars may occur both in the skin
and deeper tissues. In rare cases, keloid scars may result. Scars may be unattractive and of different color than the
surrounding skin. Additional treatments may be needed to treat scarring.

Burns – Laser energy can produce burns. Adjacent structures including the eyes may be injured or permanently
damaged by the laser burn. Burns are rare, yet represent the effect of heat produced within the tissues by laser
energy. Additional treatment may be necessary to treat the laser burns.
 Stacey Folk, MD, PC
www.folkplasticsurgery.com
303-321-6608

Color Change – Laser treatments may potentially change the natural color of your skin. Skin redness usually lasts
two weeks to three months and occasionally up to six months following laser skin treatment. There is the
possibility of irregular color variations within the skin including areas that are both lighter and darker. A line of
demarcation between normal skin and skin treated with lasers can occur.

Accutane (Isotretinoin) – Accutane is prescription medication used to treat certain skin diseases. This drug may
impair the ability of the skin to heal following treatments or surgery for a variable amount of time even after the
patient has ceased taking it. Individuals who have taken the drug are advised to allow their skin 12 months to
recover from Accutane before undergoing laser skin treatment procedures.

Fire – Inflammable agents, surgical drapes and tubing, hair and clothing may be ignited by laser energy. Laser
energy used in the presence of supplemental oxygen increases the potential hazard of fire. Some anesthetic gases
may support combustion.

Laser Smoke (plume) – Laser smoke is noxious to those who come in contact with it. This smoke may represent
a possible bio-hazard.

Bleeding – prolonged bleeding is rare following erbium:YAG laser skin treatment procedures. It is not unusual
for minor oozing following the procedure. Should significant bleeding occur, additional treatment may be
necessary.

Skin Tissue Pathology – Laser energy directed at skin lesions may potentially vaporize the lesion. Laboratory
examination of the tissue specimen may not be possible.

Visible Skin Patterns – Laser treatment procedures may produce visible patterns within the skin. The occurrence
of this is not predictable.

Patient Failure to Follow Through – Patient follow through following a laser skin treatment procedure is
important. Post operative instructions concerning appropriate restriction of activity, use of dressings and use of
sun protection need to be followed in order to avoid potential complications, increased pain and an
unsatisfactory result. Your physician may recommend that you utilize a long-term skin care program to enhance
healing following a laser skin treatment.

Damaged Skin – Skin that has previously been treated with chemical peels or dermabrasion, or damaged by
burns, electrolysis (hair removal treatments), or radiation therapy may heal abnormally or slowly following
treatment by lasers or other surgical techniques. The occurrence of this is not predictable and additional treatments
may be necessary.

Distortion of Anatomic Features – Laser skin treatments can produce distortion of the appearance of the
appearance of the eyelids, mouth and other visible anatomic landmarks. The occurrence of this is not predictable.
Should this occur, additional treatment including surgery may be necessary.
 Stacey Folk, MD, PC
www.folkplasticsurgery.com
303-321-6608

Unsatisfactory Result – There is the possibility of an unsatisfactory result form these procedures. Erbium: YAG
laser treatment procedures may result in an unacceptable visible deformities, skin slough, loss of function and
permanent color changes in the skin. You may be disappointed with the final result from laser treatments.

Pain – Very infrequently chronic pain may occur after laser skin treatment procedures.

Allergic Reactions – In rare cases, local allergies to tape, preservatives used in cosmetics or topical preparations
have been reported. Systematic reactions, which are more serious, may result from drugs used during surgery and
prescription medications. Allergic reactions may require additional treatment.

Lack of Permanent Results – Laser or other treatments may not completely improve or prevent future skin
disorders, lesions or wrinkles. No technique can reverse the signs of skin aging. Additional surgical procedures
may be necessary to further tighten loose skin.

Delayed Healing – It may take longer than anticipated for healing to occur after laser treatments. Skin healing
may result in thin, easily injured skin. This is different from the normal redness in skin after a laser treatment.

Unknown Risks – There is the possibility that additional risk factors of laser skin treatments may be discovered.

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, additional 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.

FINANCIAL RESPONSIBILITIES – The cost of the laser treatment involves several charges for the services
provided. This includes fees charged by your doctor, the cost of pre and post-operative skin care medications,
surgical supplies, laser equipment and personnel, laboratory tests and possible outpatient hospital charges,
depending on where the procedure is performed. Additional costs may occur should complications develop from
the surgery. Secondary surgery or hospital day-surgery charges involved with revisional surgery or treatments
would also be your responsibility.

DISCLAIMER – Informed-consent documents are used to communicate information about the proposed surgical
treatment of a condition along with disclosure of risks and alternative forms or treatment(s). The informed-consent
process attempts to define principles of risk disclosure that should generally meet the needs of most patients in
most circumstances. Informed-consent documents should not be considered all inclusive in defining other methods
of care and risks encountered. Your surgeon may provide you with additional or different information which is
based on all the facts in your particular case and the state of medical knowledge.

INFORMED CONSENT FOR SURGERY - SCITON CONTOUR LASER TREATMENT OF THE SKIN
 Stacey Folk, MD, PC
www.folkplasticsurgery.com
303-321-6608

1. I hereby recognize Dr. Stacey Folk, MD, Michael Bateman, MD, D. Jill Buckner, PA-C and
Heather Palmer, RN and such assistants as may be selected to perform the laser treatment.
2. I consent to the administration of such anesthetics considered necessary or advisable. I understand that all
forms of anesthesia involve risk and the possibility of complication, injury and sometimes death.
3. I acknowledge that no guarantee has been given to me by anyone as to the results that may be obtained.
4. I consent to the photographing, before, during and after the procedure(s) for medical, scientific
or educational purposes, provided my identity is not revealed in the pictures.
5. IT HAS BEEN EXPLAINED TO ME IN A WAY THAT I UNDERSTAND;
A. THE ABOVE TREATMENT OR PROCEDURE TO BE UNDERTAKEN
B. THERE MAY BE ALTERNATIVE PROCEDURES OR METHODS OF TREATMENT
C. THERE ARE RISKS TO THE PROCEDURE OR TREATMENT PROPOSED

Patient or Person Authorized to sign for Patient: _____________________________________Date:_________

Witness:_______________________________