NAIL FUNGUS (ONYCHOMYCOSIS) PRE & POST TREATMENT INSTRUCTIONS& CONSENT FORM
BEFORE YOUR TREATMENT
1. Remove all nail polish
2. Ensure nails are trimmed & cleaned thoroughly with a nail brush
3. We highly recommend the use of the SteriShoe (available for purchase at the clinic) to pre-treat each pair of shoes; if you do not have a SteriShoe apply anti- fungal spray to all shoes.
4. Do not apply any topical anti fungal (creams, oils, or powders) for 2 days prior to treatment.
5. Bring a pair of clean socks to wear home. After your treatment: To help prevent re-infection of the nail:
AFTER YOUR TREATMENT
1. Wear clean socks/shoes after treatment.
2. Wash sheets; disinfect shower/bath and vacuum carpets day of treatment.
3. We highly recommend the use of a SteriShoe) to treat each pair of shoes to be worn at least once a week for 4 weeks or if you do not have a SteriShoe apply anti-fungal spray to all shoes.
4. Try not to walk barefoot in public places (pool, gym, etc.)
5. Keep nails trimmed and cleaned (disinfect instruments after each use)
6. Always trim healthy nails first and then affected nails to prevent spreading to healthy nails.
7. Nail polish may be applied 24 hours after treatment.
8. Apply Lamasil cream or spray to the visibly affected nails twice daily.
Toenails may take 9-12 months & fingernails may take 6-9 months for complete re-growth.
Severely infected nails may take longer.
If you have any concerns do not hesitate to call the clinic.
You may require additional treatments at 4 and 6 weeks depending on the severity of the nail infection.
If further treatments are required it is important to follow-up on schedule.
ONYCHOMYCOSIS Laser Toenail Fungus Consent Form
Lasers can treat most toenail fungus by penetrating the nail and destroying the fungus embedded in and under the nail plate.
The laser used for this treatment has no effect on skin or soft tissue. In clinical studies there have been no adverse reactions, injuries, disabilities or known side effects.
As with any procedure there is some risk of side effects that are unknown.
I understand that clinical results may vary in different patients. The clinical studies, done in 2010 reveal that over 68-80% of treated patients show significant nail improvement with one laser treatment.
I understand the fungus may not be completely destroyed, that the nail may become re-infected or there may be other types of infection present.
The nail may continue to be discolored or not attach to the nail bed.
This treatment will not change the shape, width or other deformity of the nail plate.
I understand it might take up to 9-12 months for a toenail to grow back.
It may be necessary to perform additional treatments to obtain the optimum results.
With this in mind, I am choosing to try laser non-invasive treatment for toenail fungus.
I understand that photographs may be taken before and/or after my procedure.
I further agree that these photographs can be used in any manner necessary for medical documentation or publication.
I certify that I have read, or have had read to me, the contents of this form.
I understand the risks and alternatives involved in this procedure.
I have had the opportunities to ask any question that I had, and all my questions have been answered.
I agree to the terms of this agreement and release the technician and facility from any liability.
Patient’s Name (Please Print): ______
Signature: ______Date: ______
Laser Specialist Signature: ______
Vancouver Medi Spa, LTD. Business Licence # 15- 192313
1060 Hornby Street, Vancouver, BC, V6Z 1V6, Canada.
Medical History, Consent Form & Pre- Post Instructions for Fotona Laser Therapy
Vancouver Medi Spa Ltd. Buisness # 15- 192313
1060 Hornby Street, Vancouver, BC, Canada, V6Z 1V6
In order to provide you with the most appropriate laser treatment, we need you to complete the following questionnaire. All information is strictly confidential.
Top of Form
Name*
Address*
Date of Birth*
Email Address*
City*
State*
Zip*
Home Phone
Cell Phone*
Emergency Contact Name and Number*
How did you hear about us?*
Which of the following best describes your skin type?*
Are you currently under the care of a physician?*
If yes, for what?
Are you currently under the care of a dermatologist?*
If yes, for what?
Have you ever had a reaction to a previous laser treatment, heat treatment or radiation therapy?*
Do you have any of the following medical conditions? (Please check all that apply)*
Cancer
Diabetes
Herpes
Frequent cold sores
Arthritis
HIV/AIDS
Keloid scarring
Skin disease/Skin lesions
Seizure disorder
Hepatitis
Blood clotting abnormalities
Any active infection (describe during consultation)
None
Do you have any other health problems or medical conditions? Please list:*
What oral medications are you presently taking? Please List:*
Have you ever used Accutane?*
Are you currently using topical medications or creams? If so, please list:*
Have you ever had an allergic reaction to any medication? Please List:*
Do you currently have sunburn?*
Do you form thick or raised scars from cuts or burns?*
Do you have Hyper pigmentation (darkening of the skin) or Hypo pigmentation (lightening of the skin) or marks after physical trauma?*
Are you pregnant or trying to become pregnant?*
Are you breastfeeding?*
I certify that the preceding medical, personal and skin history statements are true and correct. I am aware that it is my responsibility to inform the technician, doctor or nurse of my current medical or health conditions and to update this history. A current medical history is essential for the caregiver to execute appropriate treatment procedures.*
Type your name and date
1. Discomfort – The procedure is done so precisely that surrounding tissue is minimally affected; the patient may experience a mild sensation of pain in the treated areas. Some degree of skin flushing may occur, but it typically resolves within several hours.*
2. Scarring – There is a small chance of scarring, including hypertrophic scars, or very rarely, Keloid scars. Keloid scars are very heavy raised scar formations. To minimize chances of scarring, it is important that you follow all postoperative instructions carefully. It is important that any prior history of unfavorable healing be reported.
3. Pigmented changes – The treated area may heal with lighter or darker pigmentation. This occurs more often in darker pigmented skin and following exposure of the area to the sun. It is recommended that you protect yourself from any sun exposure for at least three months following treatment. Hyper pigmentation usually fades in three to six months. However, pigment change can be permanent.
4. HSV Reactivation – The patient agrees to notify the physician if he/she has any history of Herpes viral infections, as the laser procedure may cause it to reactivate.
5. Lack of Treatment Response – There is a possibility that the targeted hairs, veins or other treated areas will not respond to the treatment. This is often a function of the specific body chemistry of the patient, including relative pigmentation and light absorption characteristics of the patient’s various body tissues.
6. Eye Exposure – There is also the risk of harmful eye exposure to laser surgery. Safeguards should be provided by the laser practitioner. It is important that you keep your eyes closed and has protective eye wear at all times during the laser treatment.
7. Photographs – I consent to be photographed before, during, and after the treatment and that these photographs shall be the property of the above doctor and may be published in scientific journals or for scientific or marketing reasons.
I certify that I have read or have had read to me, the content of this form. I understand the risks and alternatives involved in this procedure. I have had the opportunity to ask any questions that I had and all of my questions have been answered.*