Informed Consent For Laser Tattoo Removal printable pdf download

Informed Consent for Laser Tattoo Removal

Customer’s name:

Date:

I, ____________________ consent to and authorize _____________ and members of his/her

staff to perform multiple treatments, laser procedures and related services on me. The

procedure planned uses laser technology for the removal of tattoos.

As a patient you have the right to be informed about your treatment so that you may make the

decision whether to proceed for laser tattoo removal or decline after knowing the risks

involved. This disclosure is to help to inform you prior to your consent for treatment about

the risks, side effects and possible complications related to laser tattoo removal:

The following problems may occur with the tattoo removal system:

1. The possible risks of the procedure include but are not limited to pain, purpura,

swelling, redness, bruising, blistering, crusting/scab formation, ingrown hairs,

infection, and unforeseen complications which can last up to many months, years or

permanently.

2. There is a risk of scarring.

3. Short term effects may include reddening, mild burning, temporary bruising or

blistering.

A brownish/red darkening of the skin (known as hyperpigmention) or

lightening of the skin (known as hypopigmentation) may occur.

This usually

resolves in weeks, but it can take up to 3-6 months to heal. Permanent color change is

a rare risk. Loss of freckles or pigmented lesions can occur.

4. Textual and/or color changes in the skin can occur and can be permanent. Many

of the cosmetic tattoos and body tattoos are made with iron oxide pigments. Iron

oxide can turn red-brown or black. Titanium oxide and other pigments may also turn

black. This black or dark color may be un-removable. Because of the immediate

whitening of the exposed treated area by the laser, there can be a temporary obscuring

of ink, which can make it difficult or impossible to notice a specific color change

from the tattoo removal process.

5. Infection: Although infection following treatment is unusual, bacterial, fungal and

viral infections can occur. Herpes simplex virus infections around the mouth can

occur following a treatment. This applies to both individuals with a past history of

herpes simplex virus infections and individuals with no known history of herpes

simplex virus infections in the mouth area. Should any type of skin infection occur,

additional treatments or medical antibiotics may be necessary.

6. Bleeding: Pinpoint bleeding is rare but can occur following treatment procedures.

Should bleeding occur, additional treatment may be necessary.

Informed Consent For Laser Tattoo Removal