Informed Consent For Laser Tattoo Removal (Page 2 of 2) in pdf

Informed Consent For Laser Tattoo Removal Page 2

7. Allergic Reactions: There have been reports of hypersensitivity to the various tattoo

pigments during the tattoo removal process especially if the tattoo pigment contained

Mercury, cobalt or chromium. Upon dissemination, the pigments can induce a severe

allergic reaction that can occur with each successive treatment. Noted in some

patients are superficial erosions, bruising, blistering, milia, redness and swelling

which can last up to many months, years or permanently.

8. Compliance with the aftercare guidelines is crucial for healing, prevention of scarring,

and hyper-pigmentation. Aftercare guidelines include avoiding the sun for 2 months

after the procedure. If it is necessary to be in the sun, a sunscreen with SPF 25 or

greater must be used.

9. I understand that multiple treatments will be necessary to achieve desired results. No

guarantee, warranty or assurance has been made to me as to the results that may be

obtained. Complete tattoo removal is not always possible as tattoos were meant to be

permanent.

Occasionally, unforeseen mechanical problems may occur and your appointment will need to

be rescheduled. We will make every effort to notify you prior to your arrival to the office.

Please be understanding if we cause you any inconvenience.

ACKNOWLEDGMENT:

My questions regarding the procedure have been answered satisfactorily. I understand the

procedure and accept the risks. I hereby release

(individual)

and

(facility) and

(doctor) from all

liabilities associated with the above indicated procedure.

Client/Guardian Signature

Date_______________

Laser Technician Signature

Date_______________

Informed Consent For Laser Tattoo Removal Page 2