Laser Consent Form

First Name *

Last Name *

Date of birth

Date of Procedure

Doctor *

How does the Juliet Laser Treatment Work?

The Juliet Laser Treatment is a non-surgical, non-invasive procedure that uses specialised laser technology to tighten the vaginal walls without the use of incisions or sutures.

The goal of Juliet Laser treatment is to restore the original metabolism of connective tissue and improve the stare of toe mucosa by stimulating a process of neocollagenesis. The inner mucosa regains elasticity and lubrication, building thickness and softness. The results induction of symptoms such as itching, irritation and pain during intercourse can be observed immediately after the first treatment is completed.

The Juliet laser is unique in using a specialised Er: YAG laser which emits infrared light and does not injure the skin. This allows for a more targeted, precise and effective treatment with no risk of scarring, bleeding or infection. The MCL31 Dermablate laser is photothermic, meaning that it uses intensely concentrated light pulses which produce heat in place of traditional incisions. Using a patented fractional technology, the laser works by generating a fast heating pf the collagen in the vaginal tissue, stimulating a sudden contraction. This shorten and thicken collagen fibres and tighten the vaginal walls. This makes vaginal tissue naturally tighter and more elastic in the long term.

The Juliet laser vaginal treatment is quick and effective. It takes no more than 20 minutes and requires no pre-operative or post-operative care or recovery time. Normal activities can resume immediately after treatment. Most patients report almost no discomfort, other than a warming sensation, and there is generally no need for a local anaesthesia for internal treatment. (If, however, the labia are to be tightened, topical anaesthesia is usually applied.)

What conditions can Juliet Laser treat?

Vaginal Atrophy

Vaginal Atrophy is a condition which occurs following the decline in the production of oestrogen by the ovaries. It involves a gradual thinning of genital epithelial tissued and vaginal and vulvar mucosa, which then become more fragile, irritable and sensitive to trauma. Women who suffer from these conditions, especially during menopause, often experience a number of symptoms such as vaginal dryness, itching, painful intercourse, poor lubrication, decreased libido and poor vaginal muscle elasticity and tone.

Vaginal Relaxation Syndrome (VRS)

This condition is the loss of optimal structural architecture of the vagina. This process is generally associated with natural childbirth and with natural ageing. Pregnancy and birth contribute to a worsening of the condition, as does the onset of menopause, which causes a decline in hormone levels and vaginal atrophy. As VRS progresses, the vaginal muscles become relaxed with poor tone, strength, control and support. This condition frequently leads to decreased feelings of frictions and loss of sexual satisfaction by the patient.

Stress Urinary Incontinence

This condition is a form of urinary incontinence caused by a loss of support to the urethra, which is usually a consequence of damage to pelvic support structures as a result of pregnancy childbirth. Similarly, frequent high impact activities can cause athletic incontinence to develop. In either case, the condition is characterised by the leaking of small amounts of urine during activities with increased abdominal pressure (e.g. coughing, sneezing and lifting weights). Women who suffer from stress urinary incontinence have an altered connective tissue metabolism, which causes decreased collagen production and may result in insufficient support of the urogenital tract.

Stretch marks

While laser therapy may not be able to completely erase stretch marks, the treatment can help make striae (stretch marks) smoother and reduce their appearance. Thismethod removes stretch marks via laser resurfacing, eradicating the outer layer of skin to repair and regenerate skin cells

Erbium Facial Laser

Erbium facial laser resurfacing is designed to remove superficial and moderately deep lines and wrinkles on the face, hands, neck and chest.

Non Surgical Labia Rejuvenation

Lased is used to improve labia tightness + texture.

Please select which treatment you are receiving with Juliet Laser

for patients with a history of genital cold sores, it is recommended to prevent outbreaks by taking valtrex 500mg by mouth twice a day for 3 days. Please alert your doctor if you require this prescription.

How many treatment sessions are required?

In most cases satisfactory results can be obtained after the first session using the Juliet Laser. A second session after 2 months may be recommended in order to maximise the results, as the remodelling process (necollagenesis) can continue for several months after the treatment.

What risks are associated with Laser Treatment?

During the Laser treatment an ablative laser is used . This laser is able to induce a so called “micro-ablation”, which reaches the deeper layers of the mucosa without injuring the tissue. For this reason, the risks associated with traditional surgery (e.g. bleeding, scarring and infection) are virtually eliminated. Anaesthesia is rarely required for Juliet Laser treatment.

Ablative lasers are most efficacious at removing stretch marks and can come with some adverse effects like redness, raw skin, mild discomfort and scabbing before revealing new tissue. these side effects are usually temporary and can be mitigated through applying the cream until the visiable redness subsides.

Daysafter the treatment you may notice some pink discharge or redness. This is normal and in no way alarming. Should you experience any further symptoms, please contact your doctor immediately.

Potential complications such as scarring, infection, pain and altered sexual sensation may occur.

(Vaginal laser only ) I have been advised that I should abstain from sexual intercourse, heavy physical exercise and sports activities such as swimming or sauna use for the first three (3) days after the treatment.

YesNoNA - Not vaginal laser

Patient initial

I have been informed in detail about: The proposed treatment with the Juliet Laser, the required preparation and aftercare, the realistic results to expect, adverse events and possible side effects, cost of treatment

YesNo

Patient initial adverse events explained

General Juliet Questionaire

Do you suffer from any chronic or acute diseases (including metabolic disorders or high blood pressure) *

Yes No

Details

Do you suffer from vaginal infections?

YesNo

Details of any vaginal infections

Do you have cardiac pacemaker, any implants or prosthetics? *

YesNo

Details of prosthetics

Do you suffer from any blood clotting disorders (e.g. intensive bleeding from injuries or haematomas?) *

YesNo

Details of blood disorders

(clinical use only) Has the patient been advised to stop taking blood thinners during the week before treatment

Yes No

Do you have any allergies, especially against light? *

YesNo

List details of any allergies including severity and type of reaction

Are you prone to keloid scarring? *

YesNo

Do you smoke? *

YesNo

Are you or could you be pregnant? *

YesNo

If you would like to discuss any of the above information with your doctor, please list this below:

Bladder Questionaire (only to be completed if urinary incontinence procedure)

Do you sometimes feel you have not completely emptied your bladder?

YesNo Sometimes

Do you have to rush to use the toilet?

YesNo Sometimes

Do you wake up twice or more during the night to go to the toilet?

Yes No Sometimes

Do you plan your daily routine around where the nearest toilet is?

YesNo Sometimes

Do you leak before you get to the toilet?

YesNo Sometimes

Do you leak when you cough, laugh or sneeze?

YesNo Sometimes

Do you leak when you lift something heavy?

YesNo Sometimes

Do you leak when you play sport?

YesNoSometimes

Do you leak when you change from a seated position to a standing position?

YesNo Sometimes

Are you frequently nervous because you think you might lose control of your bladder?

YesNo Sometimes

If you would like to discuss any of the above information with your doctor, please list this below:

Financial Consent

Type of Appointment	Fee	Medicare Rebate
1. Pre Consult with Dr Tanchev	$105.00 (this will go towards your total procuedre fee if you go ahead)	Eligible Medicare Card Holders $41.40
2. Internal Juliet Procedure Fee	$1,490.00	No medicare rebate applicable
3. External (Labia) Juliet Procedure	$500.00	No medicare rebate applicable
4. Juliet 3 Month to pup	$700.00	No medicare rebate appliacble

I have read and understood the finances that are related to this procedure *

I have further questions regarding financial section, I would like a specialist admin team member to discuss this with me further prior to my procedure date:

Questionnaire to be completed in presence of Doctor at the time of procedure

I have had the opportunity to discuss all questions I have about the proposed treatment with the Juliet Laser and I am satisfied with the answers and the explanations I have received.

YesNo

Patient initial - questions

Based on the information above I willingly consent for my doctor to complete a course of treatment using the Juliet Laser. I acknowledge that all of the above information is understood by me and has been discussed with my doctor, and I understand the risks and requirements involved.

***Please do not sign this consent form. You will be required to sign this on the day of your procedure in the presence of your treating Doctor***

Signature

Draw signature|Type signatureClear

Doctors Signature:

Draw signature|Type signatureClear

Date and time of procedure

Procedure notes

Pain relief administered

Specific aftercare instructions provided