Patient Consent Form - Eclipse Aesthetics Page 3

INFORMATION AND CONSENT OF THE PATIENT

I am,

, a patient

who asked to be informed of the procedure used, I can make an informed decision to follow

or not the treatment.

You described the recommended procedure to use the Mechanized Epidermal Tattoo

Removal (METR) technique of the Eclipse Reverse

, the withdrawal process of tattooed

pigments in the dermal layer of the skin. The Eclipse Reverse

removes tattoos by a set of

seven micro-needle and a liquid specific to the METR technique.

Please write the following informations about your tattoo:

Your tattoo was done by:

A professional

A non-professional

Indicate the type of ink used:

Vegetable

Carbon

Metallic

Other

Do not know

Indicate the depth of the tattoo:

Indicate the creation date of the tattoo:

Please indicate, the tattooed area to treat:

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Parent category: Legal