Patient Consent Form - Eclipse Aesthetics (Page 4 of 4) in pdf

Mr. Ms.

I understand that the description of the procedure is to inform me about the technique in

order to be able to give my consent regarding this procedure or to refuse the treatment. The

provider informed me about the known and unknown risks concerning the technique and

risks concerning the planning of the procedure. I also understandd that results may vary and

cannot be gauranteed.

I have been informed about the fact that allergies to the METR solution are rare but some

patients may be sensitive to the treatment. I have been informed that this procedure could

lead to a certain level of pain and discomfort.

I understandd that the withdrawal of tattooed pigments is difficult and that there is an risk of

a scar, in particular for people prone to scars because of their type of skin. I am aware that

the color of my skin determines my compatibility with the treatment. Light skins are

better candidates to the treatment than darker skins, which may not be as suitable for the

technique.

I understand that the tattooing phase caused underlying skin changes hidden by the tattoo.

Although all efforts will be made to get back to the normal appearance of the skin, the

provider cannot guarantee that the removal process of the tattoo will not reveal the

existence of a previous scar on the treated skin.

I understand that after the treatment there is a risk of definitive lightening or darkening

of the pigmentation of my skin on the treated areas.

I have been informed concerning the necessity to follow the post-treatment procedure to

remove a tattoo.

The provider gave me the opportunity to ask questions about the procedure, the risks and

the dangers it involves. I am fully informed to give my consent with full knowledge of the

facts.

I certify that the document in question has been fully explained to me, I read it or someone

read it to me in its entirety. I understood its content. I have been provided with a copy of the

instructions to be followed concerning the post-treatment procedure.

Read, agreed and approved by

______________________________________

_____________________________________

Date

Patient Consent Form - Eclipse Aesthetics Page 4