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I give consent and authorization to Sidney Rienne MedSpa & Laser Center to treat me with cosmetic laser and/or pulsed light modalities. This includes, but not limited to, photo facials, fractional laser skin resurfacing, laser and intense pulse light hair removal, light-based treatment of pigmented or vascular lesions, intense pulse light acne reduction, and laser tattoo removal.

I understand that these procedures are purely elective, that the results may vary with everyone, no guarantee can be provided regarding the outcome of medical procedures such as these, and multiple treatments may be necessary to achieve maximum results.

I acknowledge and understand that:

  • Serious complications are rare, but possible.

  • Common side effects include temporary redness and mild “sun burn” like effects that may last anywhere from a few hours to 3-4 days.

  •  Pigment changes, including hypo-pigmentation (lightening of skin) or hyper-pigmentation (darkening of skin) lasting 1-6 months or longer, may occur.

  • Freckles may temporarily or permanently disappear in treated areas.

  • Other potential risks include crusting, itching pain, bruising, burns, infection, scabbing, scarring, swelling, and failure to achieve the desired result.

  •  Laser and intense pulse light treatments can cause eye injury and protective eyewear must be worn during all treatments.

  • I understand that sun or tanning lamp exposure and not adhering to the post-care instructions provided by SRMLC may increaser my chances of complications.

I consent to photographs being taken for use in the following areas: evaluation of treatment effectiveness, medical education and training, marketing, media stories, advertising and other sales purposes. No photographs revealing my identity will be used without my written consent. If my identity is not revealed, these photographs may be used and displayed publicly without my permission.

I acknowledge that pre and post treatment instructions have been discussed with me. The procedure as well as potential benefits and risks have been explained to my satisfaction. I have had all my questions answered. I freely consent to the proposed treatments.


I understand the submission of this consent form equates to a e-signature giving consent and authorization to Sidney Rienne MedSpa & Laser Center to treat me with cosmetic laser and/or pulsed light modalities in accordance with proposals for the use of e-signatures under HIPAA rules were included in the first draft of the 2003 Security Rule.