Consent for Patient Cosmelan Treatment

Cosmelan® treatment is a unique, safe and highly effective mean of eliminating pigmented spots as well as acne on the face and body.
Cosmelan® cream contains a high concentration of vitamins A and C and thus has rejuvenating effect on skin
Cosmelan® contains a synergistic complex of natural compounds that inhibit the production of the dark pigment, Melanin, by the Melanocytes (pigment-forming cells) in the skin.
Cosmelan® is the most effective treatment for dark patches, known as Melasma, that occur due hormonal changes and pregnancy.
Cosmelan® treatment can be carried out at any time of the year and strict sun avoidance is not necessary.

Cosmelan® treatment is comprised of two parts:

Cosmelan 1® Professional Mask:

A depigmenting mask is applied and should be kept on the skin for a minimum period of 5 hours or as recommended by your doctor, following which it should be washed off with water by the patient at home.

Cosmelan 2® Home Care:

The face and/ or body areas should be cleansed twice a day with special mesoestetic® facial wash or milk cleanser followed by mesoestetic® toner. Thereafter a fine layer of Cosmelan 2® cream should be applied once or twice a day, as recommended by your practitioner.

“NO OTHER CREAM, SUNSCREEN OR LIQUID FOUNDATION TO BE APPLIED ON TOP FOR A PERIOD OF 3 HOURS SINCE IT MAY DILUTE THE EFFECT OF COSMELAN 2®.”F

The skin will appear red; it may also peel and get very dry. Please do not be alarmed since the treatment is very safe and these effects are only transitory. In actual fact the peeling effect is highly rejuvenating and refining for the skin

Hydra-Vital Factor K® moisturizing cream and moisturizing sunscreen® may be applied several times during the day, whilst respecting the 3-hour lag period after Cosmelan 2®. This will hydrate the skin in-between Cosmelan 2® cream applications.

If the skin is still red, it is possible to alternate the application of Cosmelan 2® cream such that it is left on the skin for 3 hours only one night and 8 hours the next night.
Optional hydrating Masks 1&2® maybe used during the course of the day. Mask 1® to be used 3-4 times a week and Mask 2® twice a week. The masks have powerful skin regenerating, rejuvenating and hydrating properties.
Cosmelan 2® cream applications must continue nightly for a year after commencement of the treatment to prevent recurrence of the spots.
In the event of any untoward reaction, please contact your treating physician.
Second year of treatment, Cosmelan 2® cream should be applied three times a week at night.

FOLLOW UP APPOINTMENTS: Monthly hydration treatments are recommended during the course of treatment.

I am a competent consenting adult of at least 18 years of age (or my parent or legal guardian is giving consent on my behalf), and further:

Pre and post treatment instructions have been explained to me.
I have had the opportunity to ask questions, and all my questions have been answered to my satisfaction.
I declare that while completing the medical questionnaire, I have answered the information related to my personal medical history questions completely and I have not withheld any information.
Must notify the clinician if my medical history changes prior to subsequent treatments.
I consent to clinical photographs being taken of my treated areas for my personal health record only.
There are no refunds for services rendered and/or after a year from purchase and not used.
The treatments I receive here are voluntary and I release KAI LIFE CLINIC, my doctors, nurse and/or my technician from liability and assume full responsibility thereof for this appointment and future appointments.
My signature below constitutes my acknowledgment and understanding of all this information.

I hereby authorize and direct the doctors and/or technician to perform the treatment on me.

Patient Name

Patient Signature

Date/Time

Doctor Name

Signature

Date

Witness Name

Witness Signature