Consent Form For Tattoo Removal With The Ultralight Q (Page 2 of 2) in pdf

Consent Form For Tattoo Removal With The Ultralight Q Page 2

I understand that if I am prone to, or have ever had “cold sores,” fever blisters,” or

recurrent herpes infection of any area to be treated, I must inform Dr. ____________

and/or his technician, so that appropriate medication can be initiated prior to treatment in

an attempt to prevent a new episode of this problem. ____

Pre-treatment photographs/video footage will be obtained. I agree that any photographs

taken may be used for medical publication or teaching purposes for medical, paramedical

or laypersons. I understand that the release of this information will be kept confidential

and that my name will not be released. ____

I understand that the results of the Ultralight Q tattoo removal cannot be guaranteed and

that Dr. ______________ and/or technician have made no guarantees to me. By my

signature below, I certify that I have read and fully understand the contents of this consent

form and assume the risks associated with this procedure. I authorize the performance of

laser tattoo removal by Dr. _______________ and/or technician. ____

_____________________________________

___________________

Patient Signature

Date

___________________________________

Witness

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Consent Form For Tattoo Removal With The Ultralight Q Page 2