Keren B. Horn, MD Meyer A. Horn, MD Neha D. Robinson, MD Peter A. Lio, MD Emily Arch, MD 1455 N. Milwaukee Avenue-Second Floor Chicago, Illinois 60622 T 773.276.1100 F 773.276.1102 LASER HAIR REMOVAL LASER HAIR REMOVAL INFORMATION Laser Hair Removal utilizes specific wavelengths of light that are drawn to the pigment at the “root” or bulb of the hair. This light heats and destroys the hair follicle without damaging the surrounding skin. Hair follicles go through different cycles, and a treatment will only target those hairs that are in the “growth phase.” There is considerable individual variability in response, with most patients having a 60-75% permanent reduction of hair after 6-10 treatments. Certain body areas and certain skin types may take longer to respond. The best results are seen in patients with dark hair and light skin. You should expect that occasional maintenance or “touch-up” treatments may be necessary. PROCEDURE DESCRIPTION Each treatment will range from 15-60 minutes. With each procedure, your eyes are covered with protective eyewear. A thin layer of gel is applied to protect the skin surface. Pulses are then delivered with the laser. Each pulse can range from barely noticeable to mildly painful. Any discomfort is best described as a brief stinging or snapping. Topical anesthetic is available prior to treatment if you arrive at least 30 minutes prior to your appointment. RISKS/COMPLICATIONS Immediate redness and swelling are expected effects from the laser treatment and will most often resolve within several hours. Skin discoloration, scabbing, blisters and crusting can occur, although unlikely. In rare instances infection and/or scarring can occur. Sun exposure after a treatment can cause blotchy pigmentation, which is usually temporary but can take a few months to resolve. Cold sores can be triggered by any facial procedure. If you have a history of cold sores, be sure to notify your doctor prior to your procedure, so that you can be given a medication to reduce the chance of a breakout. There is no guarantee of results, and though it is unlikely, there may be minimal or no improvement of the condition. CONTRAINDICATIONS  Use of isotretinoin (Accutane) in the previous 12 months  Recent sun exposure and suntan —avoid the sun one month before and after treatment  Pregnancy  Keloid tendency  Photosensitivity or use of a medication that is photosensitizing (be sure to communicate with your doctor about any prescriptions you take)  History of lupus BEFORE YOUR LASER HAIR REMOVAL TREATMENT • Avoid sun exposure one month before and after treatment (VERY IMPORTANT!). Be sure to use a sunscreen that has an SPF of at least 30 and zinc oxide as an active ingredient. Apply generously and reapply every 1-2 hours. • Avoid harsh scrubs or exfoliants 1 week before and after the procedure. • Stop retinoids (like Retin-A, Differin, Tazorac, Renova, Afirm, Tri-Luma), alpha hydroxy acids/glycolic acids at least 1 week before procedure. • If you have a history of cold sores or genital herpes, please let us know before the day of the procedure so that a medication can be given for you to take. • Patients who are taking sun-sensitive oral antibiotics (such as Oracea, minocycline, doxycycline, Monodox, etc.) should discontinue these medications 3 days prior to their appointment to prevent adverse side effects. If you are not sure if your medications fall under these categories, ask your physician or provider. These may be restarted as soon as the procedure is complete. Please be aware that patients with rosacea may experience a slight flare with any temporary discontinuation of oral antibiotics. • To minimize discomfort, you may take 600mg of ibuprofen 1 hour before your treatment. • Perform a close shave of the area to be treated 2 days prior to the treatment. TWEEZING AND WAXING SHOULD BE AVOIDED while undergoing treatments. Rev 12/14/12 ed AFTER YOUR LASER HAIR REMOVAL TREATMENT      Mild redness and swelling are normal after the procedure. This is typically brief, lasting minutes to hours, but can persist up to several days after the procedure. You can immediately apply makeup and sunscreen. You may shave, but do not pluck, wax, or get electrolysis between treatments. Avoid any alpha hydroxy and retinoid products, scrubs, Clarisonic, or other potential irritants for 1 week after the procedure. Sun exposure should be avoided for one month after the treatment. Daily use of a sunscreen, SPF 30+ with zinc oxide, is recommended. COST OF YOUR LASER HAIR REMOVAL TREATMENT Area(s)___________________________________________ # of treatments____________________________________ Cost of each treatment*_____________________________ * This financial quote for treatment is valid for 90 days from the date of receipt. Prices are subject to change and an updated quote will be provided if necessary after 90 days. CONSENT TO LASER HAIR REMOVAL TREATMENT Patient Name:___________________________________________________________ DOB:___________________________ 1. I consent to the performance of Laser Hair Removal with LightSheer and/or ND:Yag within one year of date of this consent; to be performed by or under the supervision of Dr.______________________________________________. 2. The procedure has been explained to me including the benefits of the treatment, risks involved, and possible alternative methods of treatment. I have had the opportunity to discuss this procedure and received answers to all questions I asked. __________ (initial) 3. I understand that there is no guarantee that any particular results will be obtained. 4. Dermatology & Aesthetics of Wicker Park is affiliated with Northwestern Memorial Hospital, which is a teaching hospital. Medical education and research are part of the Hospital’s role. For the purpose of advancing medical education, I consent to observation of this procedure by qualified observers (including medical and nursing students). I authorize Dermatology & Aesthetics of Wicker Park employees to take pi ctures and publish the pictures in scientific journals and exhibit them for educational purposes, providing that the identity of the patient is not revealed. (If the patient’s identity would be revealed by publication of the pictures of accompanying text, they will not publish unless I specifically agree to this in writing. 5. I authorize the taking of clinical photographs to asses the effect of treatment and for the possible use for marketing, patient education and scientific purposes. I understand my identity will be protected. I have read the above and understand it. My questions have been answered satisfactorily by the doctor and doctor’s associates. I accept the instructions, risks and complications of the procedure. Patient Signature Rev 12/14/12 ed Date