Tattoo Removal Consent Form

ADVERTISEMENT

Tattoo Removal Consent Form
The undersigned:
Patient: ___________________________________
Born on: _____/_____/________
Resident of: ________________________________
Your permission is necessary before commencing any treatments. The permission form is intended to be a tool
to ensure that you have been informed about your procedure, the risks and benefits, and to provide you with a
chance to ask questions.
_____
I understand that the success of tattoo removal varies greatly depending on the age of the tattoo and
the concentration of pigment colors.
____
The number of treatments varies widely depending on who applied the tattoo (professional vs.
homemade). Most commonly 2—12 treatments are necessary to remove the pigment.
____
I understand that there is no guarantee that the laser will remove all the pigment. Black, dark blue, and
blue are easier to remove. Green, orange, and yellow are more difficult to remove.
____
I understand that a shadow of the tattoo may be present after the treatments.
____
I understand that my skin was originally scarred by the tattoo application needle. This injury may remain
even if all the pigment is removed.
____
I understand that my skin will be extremely sensitive to sunlight following the procedure. I agree to
refrain from tanning for 2 weeks prior and 4 weeks following the treatment. Maximum SPF should be
worn at all times.
I have read and understand this agreement and all my questions have been addressed and answered to my
satisfaction. I consent to the terms of this agreement.
_______________________________
____________________
Patient Signature
Date
_______________________________
____________________
Witness
Date
I, the undersigned medical professional, hereby certify that I have reviewed the foregoing treatment
consent with the named patient (including the risks of and alternatives to treatment) on or prior to the
first date of treatment and have given the patient the opportunity to ask questions regarding his or her
treatment, including the opportunity to communicate with a physician.
_______________________________
____________________
Medical Professional
Date

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go