Document 6475929



Document 6475929
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 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.
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.
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.
 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
• 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
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
Sun exposure should be avoided for one month after the treatment. Daily use of a sunscreen, SPF 30+ with zinc
oxide, is recommended.
# 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.
Patient Name:___________________________________________________________ DOB:___________________________
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.______________________________________________.
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)
I understand that there is no guarantee that any particular results will be obtained.
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.
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

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