Informed Consent for Laser Tattoo Removal

Beauty Redefined

408-356-7050

 

 

I, ____________________ consent to and authorize Beauty Redefined and members of his/her staff to perform multiple treatments, laser procedures and related services on me.  The procedure planned uses laser technology for the removal of tattoos.

 

As a patient you have the right to be informed about your treatment so that you may make the decision whether to proceed for laser tattoo removal or decline after knowing the risks involved.  This disclosure is to help to inform you prior to your consent for treatment about the risks, side effects and possible complications related to laser tattoo removal:

 

The following problems may occur with the tattoo removal system:

 

1.          The possible risks of the procedure include but are not limited to pain, purpura, swelling, redness, bruising, blistering, crusting/scab formation, ingrown hairs, infection, and unforeseen complications which can last up to many months, years or permanently.

 

2.          There is a risk of scarring. 

 

3.          Short term effects may include reddening, mild burning, temporary bruising or blistering.    A brownish/red darkening of the skin (known as hyperpigmention) or lightening of the skin (known as hypopigmentation) may occur.  This usually resolves in weeks, but it can take up to 3-6 months to heal.  Permanent color change is a rare risk.  Loss of freckles or pigmented lesions can occur.

 

4.      Textual and/or color changes in the skin can occur and can be permanent.  Many of the cosmetic tattoos and body tattoos are made with iron oxide pigments.  Iron oxide can turn red-brown or black.  Titanium oxide and other pigments may also turn black.   This black or dark color may be un-removable.   Because of the immediate whitening of the exposed treated area by the laser, there can be a temporary obscuring of ink, which can make it difficult or impossible to notice a specific color change from the tattoo removal process.

 

5.          Infection: Although infection following treatment is unusual, bacterial, fungal and viral infections can occur. Herpes simplex virus infections around the mouth can occur following a treatment. This applies to both individuals with a past history of herpes simplex virus infections and individuals with no known history of herpes simplex virus infections in the mouth area. Should any type of skin infection occur, additional treatments or medical antibiotics may be necessary.  

 

6.          Bleeding: Pinpoint bleeding is rare but can occur following treatment procedures. Should bleeding occur, additional treatment may be necessary.

 

7.          Allergic Reactions: There have been reports of hypersensitivity to the various tattoo pigments during the tattoo removal process especially if the tattoo pigment contained Mercury, cobalt or chromium.  Upon dissemination, the pigments can induce a severe allergic reaction that can occur with each successive treatment.  Noted in some patients are superficial erosions, bruising, blistering, milia, redness and swelling which can last up to many months, years or permanently.

 

8.      Compliance with the aftercare guidelines is crucial for healing, prevention of scarring, and hyper-pigmentation.   Aftercare guidelines include avoiding the sun for 2 months after the procedure.   If it is necessary to be in the sun, a sunscreen with SPF 25 or greater must be used.  

 

9.      I understand that multiple treatments will be necessary to achieve desired results.  No guarantee, warranty or assurance has been made to me as to the results that may be obtained.  Complete tattoo removal is not always possible as tattoos were meant to be permanent.

 

Occasionally, unforeseen mechanical problems may occur and your appointment will need to be rescheduled. We will make every effort to notify you prior to your arrival to the office. Please be understanding if we cause you any inconvenience.

 

ACKNOWLEDGMENT:

 

My questions regarding the procedure have been answered satisfactorily.  I understand the procedure and accept the risks.   I hereby release Dawn Martino/Sara Bradley (individual) and                Beauty Redefined  (facility) and Dr. Kazi(doctor) from all liabilities associated with the above indicated procedure.

 

 

Client/Guardian Signature                                                                      Date_______________

Laser Technician Signature                                                                     Date_______________

 

 

 

 

Tattoo Removal Aftercare Instructions

 

 

The tattoo removal laser treatment may create a superficial burn wound.  Some clients may experience bruising or swelling.  There is immediate whitening of the treated area, which usually lasts for several minutes.  Many clients then develop blisters, crusts, or scabs within 12-72 hours, which may last for 1-2 weeks or more.  The treated areas may be pink or pale after the scab separates.  Loss of skin pigment in the treated area is common, and is usually temporary.  Healing is usually complete by 6-8 weeks.

 

  1. Keep the treated area clean and dry while it is healing.  Clean the area gently with soap and water and then gently pat the area dry.  You may apply a thin coating of antibiotic ointment up to three times a day while the area is healing if you keep the area covered with a sterile dressing.

 

  1. You may apply cool compresses as necessary for 24 hours after the laser treatment to help reduce discomfort and inflammation.  You may take plain Tylenol, but avoid aspirin (it can increase the risk of bruising and/or bleeding.)

 

  1. Do not pick at the scab or allow the skin to become scraped, as this may result in infection and scarring.  Shaving should be avoided in the treated area until it is completely healed.

 

  1. Do not wear makeup or any cream or medication unless recommended by our office for 48 hours.

 

  1. Wear a sunblock with an SPF of 25 or higher over the area for 3 months following the treatment.

 

  1. If the area looks infected (honey colored crusting and oozing or spreading redness), if you experience an unusual discomfort or bleeding, if any other complications develop, or if you have any questions or concerns, contact the office immediately.  Of course, if you have any extreme reaction (such as moderate to severe facial swelling, moderate to severe rash, any difficulty breathing, or you are in any distress) call 911 and go to the emergency department.

 

 

Client/Guardian Signature                                                                      Date_______________

Laser Technician Signature                                                                     Date_______________