SCAR REMOVAL CONSENT FORM

PATIENT INFORMATION:

First Name

Last Name

Date Of Birth

Phone/Mobile

City

Next Of Kin

Kins Contact Number (Phone/Mobile)

MEDICAL HISTORY

Do you have a history of abnormal scarring, including keloids or hypertrophic scars?

Yes

If Yes, please specify:

Do you have any active skin infections, inflammation, or open wounds in the treatment area?

Yes

If Yes, please specify:

Have you used Accutane or similar medications in the past 6–12 months?

Yes

If Yes, please specify:

Have you had recent sun exposure, tanning, or use of self-tanning products on the treatment area?

Yes

If Yes, please specify:

Are you currently pregnant, trying to conceive, or breastfeeding?

Yes

If Yes, please specify:

Do you have any other medical conditions?

Yes

If Yes, please specify:

Procedure Description:

I understand that I am receiving laser scar removal treatment, a non-invasive or minimally invasive procedure designed to improve the appearance of scars using targeted laser energy.

During the procedure, a specialized laser device is used to deliver controlled pulses of light energy into the skin. This energy works by removing damaged outer layers of skin and/or stimulating the production of collagen in the deeper layers. The process helps to smooth the texture of the scar, reduce discoloration, and improve overall skin appearance.

Depending on the type and severity of the scar, different laser technologies may be used (such as Carbon or PICO lasers). The treatment may be performed in multiple sessions spaced several weeks apart to achieve optimal results.

I understand that the procedure may cause a warming or stinging sensation, and a topical numbing cream may be applied to improve comfort.

Results develop gradually as the skin heals and regenerates, and while significant improvement is often achieved, complete scar removal is not guaranteed.

Benefits and Risks:

I have been informed that the potential benefits of laser scar removal treatment may include:

Reduction in the appearance, size, and depth of scars
Improved skin texture and smoothness
More even skin tone and reduced discoloration
Increased collagen production leading to healthier-looking skin
Non-surgical solution with minimal downtime

I understand that there are potential risks and side effects associated with laser scar removal treatment, including:

Mild discomfort during the procedure
Temporary redness, swelling, or sensitivity in the treated area
Dryness, peeling, or crusting as the skin heals
Temporary darkening or lightening of the skin (hyperpigmentation or hypopigmentation)
Increased sensitivity to sunlight following treatment
Risk of infection if aftercare instructions are not followed

I understand that serious complications are uncommon but may occur in rare cases.

Aftercare:

I agree to follow the post-treatment instructions provided by the clinician to ensure the best possible results and minimize any risks. I understand that failure to adhere to these instructions may increase the likelihood of complications.

Consent for Treatment:

I hereby consent to undergo a Scar removal treatment. I acknowledge that the clinician has explained the procedure, its benefits, and potential risks to me. I have had the opportunity to ask questions, and all of my concerns have been addressed to my satisfaction. I understand that the results of a Scar removal treatment can vary, and multiple sessions may be required for optimal results.

Release of Liability:

I release The Abram, its employees, and representatives from any liability associated with the Scar removal treatment, except for cases of negligence or intentional misconduct.

Human Error Acknowledgment:

I understand that aesthetic treatments are performed by qualified clinicians using professional equipment and established protocols. However, I acknowledge that, as with any procedure involving human involvement, there is a possibility of unintended outcomes due to human or technical error. By signing this consent, I accept this inherent possibility and agree that The Abram and its staff shall not be held liable for minor or unintentional errors occurring during the course of treatment, provided that reasonable care and professional standards are followed.

Photographs and records:

I understand that videos and photos will be taken for medical documentation purposes and will be used only for treatment comparisons and tracking progress milestones.

Client's Initial

Receptionist's Initial

Technician's Initial

I agree that all the above information is true and accurate to the best of my knowledge

Client’s signature: