Client Information and

Consent for Laser Tattoo Removal

Please read this consent form carefully. This form may contain words that are unfamiliar to you. Please ask your Practitioner to explain any words or information that you do not clearly understand. You may take home an unsigned copy of this consent form to think about or discuss with family or friends before making your decision.

PROCEDURES

Laser Tattoo Removal

A special laser is used which mechanically breaks down the ink particles of the tattoo rendering them susceptible to your body’simmune system. Many treatments may be needed to fade a tattoo – the tattoo may not be completely removed. The skin where the tattoo was may become paler than previously – this may be transient or permanent. Side effects of the treatment include moderate pain, blistering and pin-point bleeding. Rarely an allergic reaction to the released ink particles can occur requiring anti-histamine treatment.

GENERAL RISKS

Eye injury due to use of the Laser is a risk to the client and to the operator; however, the risks are almost completely eliminated with the use of proper eyewear.

Your eyes will be covered during the procedure with goggles similar to those worn in a tanning booth.

The operator and any other person in the treatment room will be wearing special eyewear that filters out the potential harmful light and allows them to clearly visualize the treatment area.

CLIENT CONSENT FOR TREATMENT

My signature below constitutes my acknowledgment that I, ______,

(Print Name)

am a competent, consenting adult of at least 18 years of age (or my parent or legal guardian is giving consent on my behalf), and further, that I:

  • have read and understand the information provided in this form;
  • have had my procedure adequately explained to me by my practitioner;
  • have had the opportunity to ask questions, and all of my questions have been answered to my satisfaction;
  • have received all of the information I desire concerning my procedure;
  • understand all post treatment recommendations and agree to adhere to them;
  • freely assume any risks of complications or injury from known or unknown causes associated with, relating to, or otherwise arising out of this procedure;
  • Have the right to consent to or refuse any proposed procedure at any time prior to its performance;

Consent to, and authorise ______to perform the treatment

(Print Practitioner Name)