Genesis V

Consent Form

I hereby authorise SDL Australia to perform Genesis Non-Ablative Skin Therapy on me. I understand that this procedure works on promoting vibrant and healthy-looking skin. I understand that multiple treatments are required, and it is possible the results will be minimal or not help at all.

I am aware of the following possible experiences/risks:

Discomfort – A slight warming sensation may be experienced during treatmentRedness/Swelling/Bruising – Short term redness (erythema) or swelling (edema) of the treated area is common and may occur. There also may be some bruising.Skin Colour Changes – During the healing process, there is a possibility that the treated area may become either lighter (hypopigmentation) or darker (hyperpigmentation) in colour compared to the surrounding skin. This is usually temporary, but, on a rare occasion, it may be permanent.Itching/Dry Skin- Treatment may result in itching and/or dry skinRed Rash/Bumps – Red rash/bumps may appear after treatment. This resolves with time.Wounds- Treatment can result in burning, blistering, or bleeding of the treated areas. If any of these occur, please call our clinic.Infection- Infection is a possibility whenever the skins surface is disrupted, although proper wound care should prevent this. If signs of infection develop, such as pain, heat, or surrounding redness, please call our clinicScarring- Scarring is a rare occurrence but is a possibility if the skins surface is disrupted. To minimise the chances of scarring, it is IMPORTANT that you follow all post-treatment instructions provided by your healthcare staff.Sun Exposure/Tanning Beds/Artificial Tanning- May increase risk of side effects and adverse events.Eye Exposure- Protective eyewear (shields) will be provided to you during the treatment. Failure to wear eye shields during the entire treatment may cause severe and permanent eye damage.

I acknowledge the following points have been discussed with me:

Potential benefits of the proposed procedure, including the possibility that the procedure may not work for meAlternative treatments such as topical. Microdermabrasion, or surgeryReasonably anticipated health consequences if the procedure is not performedPossible complications/risks involved with the proposed procedure and subsequent healing period.

For women of childbearing age:

By signing below I confirm that I am not pregnant and do not intend to become pregnant anytime during the course of treatment. Furthermore, I agree to keep SDL Australia and staff informed should I become pregnant during the course of treatment.