Ambulatory No. ........................................... Resurfacing Parameters..........................................

Date.......................Dermoscopy................................ Fitzpatrick photo type................................

Patient Name (Given and Last):.............................................................................................................................

EGN (If applicable)................................................../ only the first six digits, pls. /
Address: .................................................................................................. Tel: .............................................

I would like to remove: (The patient describes in his own words)
.........................................................................................................................................................

My doctor has explained that my case will be carried out with the following procedure: a deep laser resurfacing with a fractional CO2 laser.

My doctor has explained the procedure proposed. I do understand and realize all associated risks, the risks that are specific to me, as well as to my skin type, and the possible outcomes. I was given the opportunity to ask all my questions, and discuss my concerns with my doctor regarding the proposed procedure, as well as the risks of its implementation, as well as all alternative treatment options. I am completely satisfied with the answers to all my questions, as well as with the discussion of the issues raised by me about the procedure. My doctor has explained thoroughly that all appropriate measures will be taken should during or after the procedure, possible complications arise. My doctor has explained to me what post treatment care is due and I should be exercise during the recovery period. Granted is my personal copy of this informed consent, and the information booklet.

I agree that the procedure would be photo documented to monitor the healing process. Later on, the photographs could get published or made available to public for scientific and educational purposes. I remain anonymous in each photo, as all photographs remain solely property of Dr. Julian Penev, M.D.

I declare that I want this procedure to be performed on me.
Signature of the Patient:...........................

Physician’s Statement:

I have explained: the principles and effects of that procedure, its risks, relevant treatment options and the risks associated with those treatment options, as well as all risks specific to this patient only and his/her skin. I provided the patient with an information leaflet.

After the patient has signed the informed consent I will at first perform a therapeutic predictive test - a small field of underground treatment unit with no charge to the patient, in order to orient the patient about the procedure, and the results that can be achieved. I'll do a follow up after each procedure.

A patient can get in touch with me on that telephone number: 0888781833

www.tritonlaser.com

Signature:...................