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

Levulan (Aminolevulinic Acid 20%) is a naturally occurring photosensitizing compound which has been approved by the FDA to treat pre-cancerous skin lesions called actinic keratosis. Levulan is applied to the skin and subsequently “activated” by specific wavelengths of light. This process of activating Levulan with light is termed Photodynamic Therapy. The purpose of activating the Levulan is to improve the appearance and reduce acne rosacea, acne vulgaris, sebaceous hyperplasia, decrease oiliness of the skin, and improve texture and smoothness by minimizing pore size. Any pre-cancerous lesions are also simultaneously treated. The improvement of these skin conditions (other than actinic keratosis) is considered an “off-label” use of Levulan.

I understand that Levulan will be applied to my skin for 30-90 minutes . Subsequently, the area will be treated with a specific wavelength of light to activate the Levulan. Following my treatment, I must wash off any Levulan on my skin. I understand that I should avoid direct sunlight for 36 hours following the treatment due to photosensitivity. I acknowledge that I am not pregnant.

Anticipated side effects of Levulan treatment include discomfort, burning, swelling, redness and possible skin peeling, especially in any areas of sun damaged skin and pre-cancers of the skin, as well as lightening or darkening of the skin tone and spots, and possible hair removal. The peeling may last many days, and the r redness for several weeks if I have an exuberant response to treatment.

I consent to the taking of photographs of my face before each treatment session. I understand that I may require several treatment sessions spaced 2-4 weeks apart to achieve optimal results. I understand that I am responsible for payment of this procedure for indications other than actinic keratosis as it is not covered by most insurance carriers.

I understand that m medicine is not an exact science, and that there can be no guarantees of my results. I am aware that while some individuals have fabulous results, it is possible that these treatments will not work for me. I understand that alternative treatments include topical medications, oral medications, cryosurgery, excisional surgery, and doing nothing.

I have read the above information and understand it. My questions have been answered satisfactorily by the doctor and his staff. I accept the risks and complications of the procedure. By signing this consent form I agree to have one or more Levulan treatments.

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