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SE HABLA ESPANOL
I hereby authorize Dr.Goldstein or EVA HERNANDEZ, PA, under Dr. GOLDSTEIN’s supervision to remove or lighten the appearance of vascular lesions. The procedure involves using a laser or pulsed light device to coagulate the vessels or vascular lesion. . I understand it may take multiple treatments to obtain optimal results. Although these devices are effective in most cases, no guarantees can be made. I understand I may not experience complete clearance, and that it may take multiple treatments. Some conditions may not respond at all and, in rare cases, may become worse.
The procedure may result in the following adverse experiences or risks:
I acknowledge the following points have been discussed with me:
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. Futhermore, I agree to keep Dr.Goldstein/Eva Hernandez, PAand staff informed should I become pregnant during the course of treatment.
BY MY SIGNATURE BELOW, I ACKNOWLEDGE THAT I HAVE READ AND FULLY UNDERSTAND THE CONTENTS OF THIS INFORMED CONSENT FOR TREATMENT OF VASCULAR LESIONS, AND THAT I HAVE HAD ALL MY QUESTIONS ANSWERED TO MY SATISFACTION BY MY HEALTHCARE TEAM.