NEHSNORTH EASTERN HEALTH SPECIALISTS

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1 COSMETIC DERMATOLOGY NEHSNORTH EASTERN HEALTH SPECIALISTS nehs.com.au CONSENT FORM TREATMENT OF PIGMENTATION BBL BroadBand Light I, DOB:, of authorize of North Eastern Health Specialist to perform acne treatment with the BBL on the following area(s) of my body The Dermatologists at the North Eastern Health Specialists are trained in the use of BBL and class 4 medical lasers. A certificate in the Safety of Laser Use has been obtained by all members trained in the use of this equipment at NEHS. These members include Dr Shireen K Sidhu (Dermatologist) Dr Hoang Ly (Dermatologist) Mrs Sharon Habib (Registered Nurse) Mrs Helen Marzola (Registered Nurse) Skin Rejuvenation, Wrinkle Reduction and /or Treatment of Vascular & Pigmented Lesions with BroadBand Light (BBL) The natural extrinsic consequences of aging on skin include sun damage, freckles, age spots, and redness caused by broken capillaries. Non-ablative (no removal of body tissue) treatment is a technique for eliminating blemished areas from the skin and improving skin texture. This is a useful treatment method for both aging and sun damaged skin. With the selective choice of filters, the BBL can selectively remove these signs of photoageing and hence rejuvenate the skin.

2 Facts about the treatment of pigmentation with the BBL Multiple treatments may be necessary to achieve complete satisfaction. If brown spots are the target, BBL penetrates the skin to reach the melanocytes. The particles of the cells left behind will peel or slough off within 7-14 days. If redness is the target, blood vessels in the deeper layers of the skin absorb the light and the heat created by the light damages the vessels. The vessels are shut down and the body continues to absorb the destroyed vessel remnants. Benefits of this treatment include the possible reduction of fine wrinkles and reduction or elimination of unsightly pigmented lesions like solar spots or uneven skin color. Small red and blue vessels may be reduced or diminished. There may however also be possible unwanted hair reduction at site of treatment Light from a laser can be harmful to eyes and wearing special safety eyewear is necessary at all times during the procedures. Light from BBL is an intense burst of light and even though the special safety eyewear is in place, you will sense light emanating from the treatment area. The sensation of light may be uncomfortable in certain areas and feel like pin pricks or bursts of heat. Usually the use of topical anesthetic is avoided in light-based acne procedures. The use of topical anesthetics is at the discretion of the practitioner as there are known severe allergic reactions to ingredients in topical anesthetics. Patient s with known allergies to anesthetics will list them here: Common side effects and risks A mild sunburn-like sensation is expected. It may last from 2 hours to 24 hours. An initial flare-up of acne in the first and second session. This usually subsides with each subsequent session. If some of the blemishes form scabs, do not pick, scratch, or remove. Gentle non comedogenic emollients should be applied and this will reduce the itch sensation and the desire to scratch. Your Dermatologist will advice you on which type to use. Erythema (redness) in the area of treatment. This may last several hours. Edema (swelling) of the skin in the treated area. Urticaria (itching) or hive-like appearance is also associated with the thermal light affecting the surrounding skin. Purpura (bruising) is seen when a blood vessel bursts. These symptoms usually subside in a few hours. A cool compress placed on the area provides comfort. The treated area should be cared for delicately for at least hours. Limited activity to reduce excessive perspiration may be advised as well as no hot tub, steam, sauna, or shower use. A blister can form up to 48 hours after treatment. An antibiotic cream or ointment may be required if infection is suspected and this will be prescribed by your Dermatologist. Other short term effects include bruising, superficial crusting, and discomfort.

3 Hyperpigmentation (browning) and hypopigmentation (lightening) have been noted. This sideeffect is greatest with those of Fitzpatrick skin type V and VI. (You will be asked to fill a medical questionnaire where the Fitzpatrick skin types are listed). These conditions usually resolve within 2-6 months, but permanent color change is a rare risk. Vigilant care must be taken to avoid sun exposure (tanning beds included) before and after the treatments to reduce the risk of this color change. Sunscreen and / or sun block should be applied when sun exposure is necessary. Infection is not usual however herpes simplex virus infections around the mouth (cold sores) can occur following treatments. This applies to both individuals with a past history of the virus or individuals with no known history. Should any kind of infection occur, please contact NEHS so your Dermatologist can prescribe appropriate medical care. Allergic reactions are uncommon from treatment. Some persons may have a hive-like appearance in the treated area as discussed above. Some persons have localized reactions to cosmetics or topical preparations. Systemic reactions are rare. Please tick the following boxes when you are satisfied that the information provided is acknowledged by yourself. If you are uncertain, your Dermatologist is there to discuss this further with you. Please understand that it is crucial you follow the pre and post instructions. In general, BBL is safe with no/minimal complications experienced when conducted by experienced medical and nursing staff. A test area will be performed to ensure that your skin reactions are appropriate. I understand that all standard safety precautions and all BBL specific guidelines will be followed to ensure the utmost in safety during my treatments. This includes the use of protective eyewear at all times while the equipment is in use. I am aware of alternative methods of treatment such as topical products, oral treatments and other light-based or laser systems as discussed with my Dermatologist. I have explored such alternatives to my satisfaction, and have made an independent decision to proceed with BBL treatments. I understand that some rejuvenation is achieved in nearly everyone, but that complete clearance may not occur. Results are limited by the equipment capability as well as personal skin characteristics. My Fitzpatrick skin typing has been analyzed, and I understand that a higher Fitzpatrick typing increases the potential risk of the treatment. Hormonal therapy and other medical conditions may also affect my results. Acne treatment with BBL is limited to skin types I-V as complications of the procedure increase with greater skin types. These issues will be discussed at the time my medical history is reviewed. Results are cumulative; therefore a series of treatments is necessary to achieve maximum benefit. Actual results cannot be guaranteed. I will avoid sun tanning, tanning booths and tanning creams for at least 3 weeks prior to and after all BBL treatments as this will reduce the effectiveness and increase side effects.

4 I understand that Roaccutane (or other Retinoids taken orally) should not be used for 6 months prior to this procedure. Retin-A (or similar products containing isotretinoin) should not be used 24 hours prior to treatment to minimize irritation. These topical retinoids may be used again one week after the procedure. I understand that treatments cannot be done on skin areas with open sores or lesions. I understand that tattoos and permanent makeup may be altered and that moles may be lightened. We therefore do not treat disease within tattoos and all moles are covered up so as to not be accidentally treated. I understand that recurrent viral infections such as herpes simplex (cold sores) or varicella (shingles) may be activated and that NEHS needs to be informed if there is a history of this. An oral antiviral treatment may be prescribed over the 3 days before, during and after laser/bbl treatment in order to reduce the risk of this infection. I understand that hair growth in the treated area may be affected and therefore every attempt is made to avoid such areas. This will be discussed with you at consultation. If I have a personal or family history of skin cancer especially a malignant melanoma, I have been advised to inform the Dermatologists at NEHS before having pigmented lesions treated. As it is not uncommon to have moles on the face in regions of acne, these moles need to be protected. In addition, not all pigmented lesions are benign and it is therefore crucial a Dermatological consult takes place first to ensure the right lesion is treated. There are also many benign pigmented lesions and not all of them respond to this treatment if the BBL has been employed to treat pigmented lesions primarily. I will advice my dermatologist if I am on any anticoagulant (blood thinning) medication (including aspirin) or if there is a history of excessive bleeding or bruising. I will also inform my dermatologist if I have had a history of sun sensitivity or if I am using any sun sensitizing medications. I agree to provide NEHS with an accurate personal medical and drug history prior to treatment. As laser lights may bounce of reflective objects, I understand that all reflective objects such as jewelry and watches must be removed if near the treatment area. I understand that the sensation generated by the light pulse is most commonly described as a rubber band snapping against the skin, and most individuals are able to tolerate this sensation for the short duration of the treatment. I understand that I may have a sunburn type sensation in the treatment area for several hours afterwards and may also experience temporary redness similar to sunburn. Some skin swelling (edema), bruising, blistering, scabbing, infection and other skin changes may also occur especially following facial treatments. I understand that in most cases, all of these effects should resolve over the next several hours to days following treatment. I understand that cold compresses are beneficial, and in

5 extreme cases a mild steroid cream or antibiotic may be necessary and will be prescribed by your Dermatologist. Scarring is extremely rare and usually occurs in those with a predisposition such as a history of keloids or other excessive scarring, but acknowledge that scarring is possible with any patient. I have been advised not to undergo BBL treatments if I have such a history and under these circumstances acknowledge that NEHS cannot be responsible for the outcome of my treatment. I understand that hypo-pigmentation (decreased skin coloration) or hyperpigmentation (increased skin coloration) is uncommon, but if it occurs to me, although rarely permanent, may last several weeks to months. I understand that post treatment use of sunblock is advised to minimize the risk, and that in some cases bleaching creams add additional benefit. Your Dermatologist will guide you on whether this is necessary. I acknowledge receipt of pre and post treatment instructions and that I fully understand that failure to follow these may affect my treatment outcome and increase the likelihood or severity of complications. I also agree to carefully follow these post treatment instructions to reduce the likelihood or severity of any skin changes. Although long term risks of BBL causing pigmentation is not fully known, these complications are unlikely. Studies done have supported their safe use when used by trained individuals. However NEHS cannot be held liable for any BBL risk not yet discovered or is commonly known. I agree that this consent shall apply to all subsequent treatments of a similar nature. I understand that although every reasonable effort will be made to achieve a desirable outcome no guarantees are stated or implied. I certify that I am a competent adult of at least 16 years of age (Minors (under 18 years of age) require additional consent from a parent or legal guardian.)

6 Photography I do or do not consent to photographs and other audio-visual and graphic materials before, during, and after the course of my therapy to be used for medical, marketing, and education purposes. Although the photographs or accompanying material will not contain my name or any other identifying information, I am aware that I may or may not be identified by the photos. I have read and understand all information presented to me before signing this consent form. I have been given an opportunity to have all of my questions answered to my satisfaction. I understand the procedure and accept the risks. I agree to the terms of this agreement and give consent to the use of the Sciton BroadBand Light (BBL) system in the hope of attaining the desired beneficial results. Patient s Name (Printed): Signature of Patient Signature guardian (if patient under 16 ): Date: Witness: 230 St Bernards Road, Hectorville, SA 5073 Phone: fax: info@nehs.com.au