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Fraxel Laser Treatment Consent Form Mobile App

This Fraxel Laser Treatment Consent Form app is designed to provide your clients with the information they need to make an informed decision on whether or not to have Fraxel treatments performed. This app details treatment, risks, contraindications and more. Also includes signature capture for consent to the treatment. Have your clients complete this critical consent right from a smartphone or tablet.

  • Lendlease
  • The Cooperative
  • PG&E
  • Red Bull
  • Mirvac

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Take a peek inside the Fraxel Laser Treatment Consent Form Mobile App

Included Features

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Included Fields

Customize to add, remove, or edit any of the fields below.

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    I have requested treatment on the following areas:

  • Ico checkbox

    Face

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    Neck

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    Chest

  • Ico checkbox

    Hands

  • Ico checkbox

    Arms

  • Ico checkbox

    Other

  • Ico statictext

    Fraxel Laser treatment is FDA cleared for correction of wrinkles and lines, correction of pigment...

  • Ico textbox

    I understand that a single procedure will not remove all my skin problems completely and that opt...

  • Ico textbox

    I understand that each individual’s response will vary according to their skin type, area being t...

  • Ico textbox

    I understand that post treatment skincare products to heal my skin are required at an additional ...

  • Ico checkbox

    I do not have diabetes, autoimmune disorder, or history of cold sores.

  • Ico checkbox

    I am not pregnant and I am not breastfeeding.

  • Ico checkbox

    I am not using Accutane nor have I been on Accutane in the last year.

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    I do not have a history of keloid scar formation or poor wound healing.

  • Ico checkbox

    I do not have allergies to Lidocaine or Tetracaine.

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    HERPES SIMPLEX- I understand that if I have ever, in my life, experienced a cold sore in the same...

  • Ico statictext

    SIDE EFFECTS- The nature of the Fraxel procedure has been explained to me.

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    PAIN- Most people feel some heat-related discomfort during the treatment.

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    REDNESS AND SWELLING- Laser treatment will cause varying degrees of redness and swelling in the t...

  • Ico statictext

    ITCHING- This can occur as part of the normal wound healing process or may occur as part of infec...

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    ACNE OR MILIA FORMATION- A flare-up of acne or formation of milia, tiny white bumps or small cyst...

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    PIGMENT CHANGES- During the healing phase, the treated area may appear to be darker.

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    HYPO-PIGMENTATION- In some patients who experience pigment changes, the treated area loses pigmen...

  • Ico statictext

    BLEEDING; OOZING; CRUSTING- Aggressive treatment may cause pin point bleeding and/or oozing.

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    BLISTERS; BURNS; SCABBING- Heating in the upper layers of the skin may occasionally cause blister...

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    SCARRING- Scarring is a possibility due to the disruption to the skin’s surface and/or abnormal h...

  • Ico statictext

    INFECTION- This is rare following treatment if proper skin care is used after the procedure.

  • ...and More!

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