Self Assessment
Choose Consent Form
tattpp pigmentation removal consent form english
File Number:
TATTOO & PIGMENTATION REMOVAL CONSENT FORM
• In some cases the tattoos’ ink could leak around the area and change color
• Expect frosting during the treatment
• Expect reactions on the treated areas like: darkening, blisters, Keloids, swelling, burns, scars, hypopigmentation, hyperpigmentation, itching and redness
• Side effects can be diminished with time but in some cases can stay longer or even permanent.
• History of any Dermal Fillers / Botox or Tattoos must be informed
• The number of sessions for different areas could be more or less.
• Time between each session is necessary 6 - 8 weeks.
• Procedure timings vary from area to area and patient to patient
• Laser treatments are not advised for pregnant women.
• Laser treatments are not recommended right before an important event because reactions vary after each session.
• The number of sessions for the different areas varies from person to person therefore results cannot be estimated.
• Protective eyewear (shields) will be provided to you during the treatment. Failure to wear eye shields during the entire treatment may cause severe and permanent eye damage.
• Choice of suitable machine for the treatment is done by the doctor
• The results are staged, no guarantees can be or have been made
• There are no refunds for services rendered
I 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:
• Pre and post treatment instructions have been explained to me
• Have had the opportunity to ask questions, and all of my questions have been answered to my satisfaction
• Must notify the clinician if my medical history changes prior to subsequent treatments
• I consent to clinical photographs being taken of my treated areas for my personal health record only
• My signature below constitutes my acknowledgment and understanding of all this information
Patient Name
Patient Signature
Date/Time
Parent or Guardian (if patient is minor)
Witness
Patient Signature
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