AGREEMENT TO ASSUME OF RISKS OF TREATMENT & RELEASE OF LIABILITY

Please Read Carefully : This Agreement Affects Important Legal Rights

Patient's Name : ….........................................................................Date of Birth : …...................

Sex : …...........Age : ….................IC Number :................................Nationality :.......................

Address : ….....................................................................................................................................

….......................................................................................................................................................

Post Code : ….................... Handphone : ….......................Fixed Line :....................................

If you cannot be reached or an emergency, please contact :

Name :.....................................................................Age :...........................

Handphone : …........................Fixed Line : …...........................Relationship :........................

Family Doctor : ….................................. Phone :...........................

Special Note (If Any) :.................................................................................................................

ASSESS YOUR HEALTH STATUS BY MAKING ALL TRUE STATEMENT

(LEAVE BLANK IF IT DOESN'T APPLY TO YOU)

Allegies :...........High Blood Pressure :............Asthma :.............. Contact Lenses :.................... Convulsions :.......Diabetes :.......Migraines :....... Heart Trouble :.......Mental Disorders :........ Epilepsy/Fainting :....... Recurring Sore Throat/Ear Infection :............ Medications Currently Taking :....................................... Pre Existing Injury Currently Being Treated :.......................... Medical Conditions Currently Under Treatment :.......................................Skin Treatment History :................................. Skin Treatment Currently Taking :..................................................

Medical Symptoms :

Your experience chest discomfort with exertion :............. Your experience dizzines, fainting or blackouts :............. Your experience unreansonable breathless :................ You take heart medication :................... You Take high blood medication :............................

You are pregnant or given birth within the last 2 months?:......................

I hereby grant permission to Klinik Qistina staff to administer immediate medical treatment as deemed necessary to me should me be injured during the treatment with the Klinik Qistina. Further, I understand that I am responsible for payment of expenses incurred relating to my medical tretament.

I acknowledge and understand the risks involved in this treatment and grant permission for me to attend and assume those risks. I Further agree the risks involved in the treatment and assume these risks and accept personal responsibility for the damage at the present and future. Further, I will not sue or make a claim against any of the relevant parties.

Klinik Qistina strives to provide the maximum in safety procedure and guidelines and therefore cannot assume responsibility for any failures, risks, accidents or injuries that may occur.

By placing my initials on this agreement, I confirm that I have read the list of assured risks and agree for my self or swaid minor to assume the specific risks of treatment in the Klinik Qistina which are itemized above.

I, (patient's name) ................................................................... (signature): ........................................

Date:...............................Time :..........................

Klinik Qistina :(doctor's name)............................................(signature):........................................

Date :................................Time :.........................

IMPORTANT

Principle of Treatment :

"Patients receiving strong light theraphy should be effectively got eye protection"

Our Fractional CO2 Laser treatment stimulates your skin's natural healing process, resulting in accelerated collagen production and a renewal process that takes years off your skin. Fractional CO2 laser skin resurfacing can remedy a number of common skin concerns. Our most anti-ageing laser procedure, the Fractional CO2 laser technology can treat lines and wrinkles, improve overall skin tone and elasticity and restore a youthful glow. Fractional CO2 laser resurfacing also finally offers a solution for Acne Scarring, Sun Damaged skin and pigment disorders such as melasma and stretch marks. This treatment is for you if:

You wish to improve the overall quality tone and texture of your skin

You want to minimise acne scars, stretch marks or surgical scars

You desire smoother, fresher, younger looking skin

You wish to improve fine lines around your eyes

Prohibited :

1) Pregnant

2) Isolation in the sun

3) Sensitive to light or medicine, or are taking medicine that sensitive to light

4) Using Vitamin C within 6 months

5) Not representative naevi or malignant pathological changes in treatment area

6) Herpes or trauma

Attentions in Treatment :

1) Adjust energy from low to higher or may burn skin

2) It's not short than 3 weeks every treatment

3) Water prohibited on treatment area in 5 - 7 hours.

4) Isolation prohibited on treatment area in 7 days

Its not allowed to use CO2 mode beyond professional doctor.

Treatment for :

Sun Damage Recovery, Remove intractable, Skin Renewing, Skin resurfacing, Wrinkle Removal, Skin Tightening, Acne, Acne Scar, Melasma, Pigmentation, Burn Scar, Surgery Scar, Traumatic Scar, Vitiligo,Uneven skin tone, Reduce skin swalloniness

Put topical Retinoids to improve skin texture regeneration and reformation optimum.

Darker or alive skin : Put topical lightening agent

Put Hydraquinone to reduce complication such as post inflammatory hyper pigmentation (Darkening of the skin in the treated areas as a result of treatments).

Heavier Treatment : Anti Viral Medication or antibiotic may need to be taken prior to the procedure to prevent infections.

What is Fractional CO2 Laser Treatment?

Fractional CO2 Laser Treatment is a 'fractional' treatment that treats minute sections of the skin, which penetrate into the dermis to stimulate significant collagen renewal. The surrounding non-affected areas of the skin aid the body’s natural recovery process for dramatic results without significant recovery time. As the new collagen filled cells replace the old tissue the skin has an even tone, becomes plumper, smoother and less lined.

What does treatment feel like?

A warm, heating sensation may be felt but is considered very tolerable by most people. The system has an inbuilt cooler which will cool the skin first, ensuring treatment is more comfortable.

What should I expect after treatment?

Your skin may appear redness,swollen,hot and flushed for a few hours (4 – 8 hours) after treatment. However, our Fractional CO2 Laser is unique and treats the tiniest section of skin in comparison to other fractional lasers. Therefore, any redness or swelling is very minimal. As the old skin tissue sheds your skin may appear more bronzed or tanned for a few days (5 – 7 days) post treatment. Your skin will naturally exfoliate and may flake as if you have mild sunburn.

How many treatments will I need?

We often advise a series of three to six treatments for optimal results. If acne scarring is your primary concern you may require additional sessions. Treatment is carried out every three to six weeks but your laser clinician will advise the optimal frequency during your consultation.

Are there any side effects?

Side effects are rare but could include a small blister. Any blistering is superficial and would heal within a week or two.