Patient Informed Consent Form

Juliet Laser for Vaginal Health

I hereby authorize Alana Sullivan under Dr. Dembny’s supervision to perform the Juliet Laser treatment. The Juliet is an Er: YAG 2940 nm laser incorporating a unique treatment protocol delivering two passes to the vaginal area to stimulate collagen and revitalize the vaginal tissue to address symptoms associated vaginal atrophy and vaginal relaxation. The laser can treat the labia and vulvar tissue to improve the appurtenance and dyschromia in vulvar area. It may take multiple treatments to obtain optimal results, and it is possible that the results will be minimal or not help at all. The results may be temporary or permanent and there is no way to predict how long the results will last. Although these devices are effective in most cases, no guarantees can be made.

The procedure may result in the following adverse experiences or risks:

  • DISCOMFORT/PAIN - Some discomfort and/or pain may be experienced during treatment. A topical anesthetic will be applied to your skin before external vaginal treatment. Other forms of anesthesia, or pain management, may also be used.

  • PINK DISCHARGE/SPOTTING - Pink discharge or spotting may be present for 3-4 days post-treatment.

  • INFECTION - Infection is a possibility whenever the skin surface is disrupted which can lead to scarring. Proper would care and keeping the treated area clean are important. If signs of infection develop, such as pain, heat, blisters, or surrounding redness, please call our office (414) 529-8400 or email epic1@epicmedspa.com

  • CONTACT/ALLERGIC DERMATITIS OR SKIN SENSITIVITY - Potential increased sensitivity, irritation/itching or allergic reaction of the skin due to skin surface disruption.

  • ALLERGY - There is a risk of an allergic reaction to the numbing cream.

  • EYE EXPOSURE - Protective eyewear (shields) will be provided to you during the treatment. Failure to wear eye shields during the entire treatment may cause severe and permanent eye damage.

I acknowledge the following points have been discussed with me; Potential benefits of the proposed procedure, including the possibility that the procedure may not work for me; alternative treatments; Reasonably anticipated health consequences if the procedure is not performed; possible complications/risks involved with the proposed procedure and the subsequent healing period; instructions to refrain from intercourse for a least 72 hours post-treatment; instructions to avoid hot tubs, baths or swimming for a few days post treatment; and post-treatment care instructions.

By submitting below, I confirm that I am not pregnant and do not intend to become pregnant anytime during the course of treatment. Furthermore, I agree to keep Alana Sullivan, Dr. Dembny informed should I become pregnant during the course of treatment. I certify the following:

  • That I have received an up-to-date (within 12 months) and normal PAP test and gynecologic exam.

  • That I am not menstruating at the time of treatment.

  • That I do not have any active infections in the treatment area.

  • I am not pregnant or have any active cancer.

  • I have cleared treatment with my managing physician for any on going or past cancer or disease.

  • I have been free from ALL chemotherapy and radiation for at least 1 year.

  • I have been clear of any Sexually Transmitted Disease or infection in the treatment area for 6 months.

  • I have not had intercourse for 24 hours prior to treatment.

  • I will follow ALL aftercare instructions and notify the clinic with post treatment concerns.

  • Return for a follow-up appointment in 4 to 6 weeks.