Consent Form For Tattoo Removal With The Ultralight Q

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CONSENT FORM FOR TATTOO REMOVAL WITH THE ULTRALIGHT Q
This form is to provide you with information that you may need to make a decision
regarding laser tattoo removal with the Ultralight Q Laser. If you have any questions or
do not understand anything in this form please ask your physician/technician before
signing. Please initial the line at the end of each paragraph indicating that you have read
and understand it.
I, ________________________________, herby authorize and direct Dr. ______________
and/or technician to perform laser assisted tattoo removal with the Ultralight Q Laser. The
procedure and necessary post-treatment care have been explained to me in terms that I
understand. I have had the opportunity to ask questions about the procedure, including
expectations from the treatment, and have had all of my questions satisfactorily answered.
I shall keep all of my post-treatment appointments so that healing can be monitored and the
development of any complications can be discovered early and treated appropriately. ____
I understand that the Ultralight Q Laser works on tattoo ink. As there are a variety of
tattoos (colors, professional vs. amateur), it may require several sessions to complete a
course of treatment. Discoloration (of the original color or of a lighter or darker color) may
be observed even with multiple laser procedures. ____
Since the laser treatment involves subjecting the skin to an intense beam of light,
immediate side effects that can be observed include redness, swelling, itching and
blistering. A delayed side effect can include alteration in pigmentation: the treated site can
appear somewhat lighter or darker than the surrounding skin, or as discussed above,
different colors from the original ink may appear. Although this alteration usually fades
spontaneously over time, some alteration in pigmentation may persist. Scarring (raised,
depressed, red) may also develop as a result of treatments. ____
Protective eyewear will be provided during the treatment. It is important to keep these
goggles on at all times during treatment. ____
I understand that certain medications can make the skin more sensitive to light, including
laser light. I do not currently use any medication – or I have listed them all on the
following lines. ____
Oral medications: ____________________________________________________
Topical products/medications: __________________________________________
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