State-of-the-art, personalized skin care
from experienced professionals
“A regular skin checkup can literally save your life.” Jennifer Krasnoff, MD

I understand that the purpose of Intense Pulsed Light (IPL™) therapy is for photo-rejuvenation, and for removal of benign vascular and pigmented lesions.

I understand that on average 3-5 treatments are suggested to significantly reduce my unwanted lesions, and that 100% clearance in the treated area is unlikely. Individual response will vary according to skin type, hair color, degree of tanning, follow up care, and the body area being treated.

I understand that there are rare possible side effects such as scarring and permanent discoloration as well as short-term effects such as pain, swelling, redness, bruising, blistering, mottling of pigmentation and unforeseen complications. Eye injury is possible but unlikely, providing complete eye protection is properly used throughout laser treatment sessions.

I understand that this cosmetic treatment will not be covered by medical insurance. I agree to take full responsibility for payment of the charges incurred.

I agree that pre- & post-operative clinical photographs and videos may be taken to monitor my treatment progress and for patient educational purposes. I understand that my identity will be protected.

I certify that I have read and understand the contents of this consent form. I have been given the opportunity to ask the doctor/staff any questions that I have about the procedure, and all of my questions have been answered. The doctor/staff has explained the procedure and its alternatives to me, and I both understand and accept the risks involved in this procedure.

Please download this PDF form to sign.

 


 

 

 

Petaluma Office
165 Lynch Creek Way
Petaluma, CA 94954
 M-F, 8:00am-5:00pm
(707) 762-5531
Fax: (707) 762-5976

 

 

Hercules Office
500 Alfred Nobel Dr., Ste. 245
Hercules, CA 94547
M-F, 8:00am-5:00pm
Open Saturday for aesthetic services
 (510) 741-7418
Fax: (510) 741-7456

 

Billing office
510-741-7299
Fax: 510- 741-7493

 


At Dermatology Associates of the Bay Area, our board-certified dermatologists serve patients at our Petaluma and Hercules offices. We are committed to the highest standards, and we offer a full range of cosmetic, medical, and surgical dermatology procedures, as well as quality skin care products.

Dermatology Associates of the Bay Area
165 Lynch Creek Way | Petaluma, California 94954 | Phone: (707) 762-5531 | Fax: (707) 762-5976
500 Alfred Nobel Drive, Suite 245 | Hercules, California 94547 | Phone: (510) 741-7418 | Fax: (510) 741-7456