PICOSURE TATTOO REMOVAL CONSENT FORM

     

     

     

    Date:  

    Time:

     

     

    PERSONAL INFORMATION 

    First name: 

    Last name: 

    Email address: 

    Address: 

    Post code: 

    City: 

    Repeat customer?  

    How did you hear from us... 

    D.O.B 

     

    Changes to medical history:

     

    Sun exposure or other forms of tanning in the last 4 weeks?  

     

    Treatment Information

    The PicoSure laser produces an intense burst of light that is absorbed by the pigmented lesion or tattoo ink. All personnel in the treatment room, including me, will wear protective eyewear to prevent eye damage from this intense light. The sensation of the laser light on skin is uncomfortable and may feel like a slight pinprick or the sensation of heat. These sensations may last for a few hours.

    Prior to the treatment, test spots may be performed. Test spots help to determine effective treatment settings.

    Tattoos may blister and have pinpoint bleeding for a few days after treatment.

    Following a pigment treatment, the treated areas may be red, slightly swollen; pigment may darken and slough off in 7-10 days.

    The area should be treated delicately following treatment. Do not pick on scabbing/blistering.

    Multiple treatments may be necessary.

    I have been informed that hyperpigmentation (darkening of the skin), and hypopigmentation (lightening of the skin) are possible complications of the procedure and incidence of this occurring are higher for darker skin types:

    I understand that sun exposure, as well as not adhering to the posttreatment instructions provided to me may increase my chance of complications.

    I agree to have before and after pictures taken of the area to be treated:

     

    yesno

    I understand that there are no refunds on the courses I purchase. yesno
    I can confirm that I am 18 years or older and I voluntary came to COMPANY NAME for tattoo removal treatment using LASER. I have answered the personal and medical history questionnaire fully and to the best of my ability. I also understand that it is important to tell my practitioner of any changes in my personal and medical status such as new medications, new illness, pregnancy, sun exposure or other forms of tanning, etc. yesno
    I confirm that I was given sufficient information to enable me to understand the treatment in accordance with its approved indication. yesno
    I have received information regarding possible adverse effects after tattoo removal treatments.  yesno
    I agree to acknowledge that risk of burning exists in the event of tanning residue. If I feel a more or less intense pain with a sensation of heat, I understand I need to call an COMPANY NAME Doctor as soon as possible to follow the specific aftercare. Usually, if burns occur they are superficial and crusting can appear, as well as hyper or hypo pigmentation. All of which are temporary, crusts will fall within 15 days and hypo-pigmentation marks will disappear after new tanning season. Please ensure all areas of skin treated are hydrated with a healing cream as much as possible. yesno

    I have received after care instructions and I understand that it is important to commit to following my practitioner's pre & post treatment care instructions: daily use of sun protection, no other heat treatments, exfoliation or swimming pool activity 7 days before and after the treatment and keeping the area cool (loose clothing), avoid exposing the treated area to the sun and solarium and other forms of tanning 4 weeks before and until the tattoo has healed post treatment, laser cannot be performed when taking photosensitising medication and will commence 1 month after the last pill. 

    I understand that results from this treatment may vary for each individual patient and good results are not always guaranteed.  yesno
    I have been given the opportunity to ask questions regarding the treatment and these have been answered to my satisfaction. 
    I understand that there is a 24 hour appointment cancellation policy and that I have to strictly adhere to my appointment time. Please note you may not be able to see the same staff member at the time you want.
    I have been correctly informed about this treatment and I consent to the above procedure.
    I have read and understood COMPANY NAME Terms & Conditions.

     

    Patient's signature >> Sign at document footer <<

     

    Practitioner's name
    Practitioner's signature >> Sign at document footer <<

     

     

    Date of last treatment: 

    Patch Test?  

    Select Client's Skin Type today  

    Has the client signed the consent form?  

     

    Location of the tattoo:

    Area to be treated:

    Age of tattoo: 

    Ink colors:

    Description of the tattoo:

    Size of tattoo:

    Patient has history of red ink or other allergies?  

    If yes, please list allergies:

     

     

    Reaction (select appropriate answers) Aftercare (select appropriate answers)