their staff to perform multiple tattoo or pigmented lesion”scars” laser lightening/removal treatments, laser
procedures and related services on me

I understand that:

• Laser energy can cause eye injury and everyone in the room during laser use, including me, must wear protective eyewear.
• I must strictly follow the post-treatment instructions given to me and all other regimens discussed to reduce procedural risks.
• Each laser emission may feel like a snap of heat or burn in the treatment area, causing discomfort, for which an anesthetic cream or injection may be used to minimize the pain. Sedation may be advisable for my treatment.

I hereby declare that

• I never have experienced any adverse reaction to anesthesia or sedatives, including, but not limited to, lidocaine, epinephrine, sodium bicarbonate, barbiturates, benzodiazepines, antihistamines, or steroids. I hereby consent to the administration of any anesthesia or sedation considered necessary or advisable for my procedure(s). All forms of anesthesia involve risk and the possibility of complications, injury, and in rare instances death.
• Results vary with each individual, and I declare that no guarantees or promises have been made to me concerning the results of any procedure or treatment and that it may take me several visits and treatments over time to see final results if at all.
• The procedure is elective, and not having this procedure or stopping a treatment always is an option.
• There may be people other than my treatment provider in the room during my tattoo laser treatment to assist, observe, or
• learn about the use of the laser, the treatments, and laser technology. I freely consent to their presence and understand that I can ask anyone to leave or not be present at any point in the treatment

The treatment can be beneficial, but I also understand that the following problems may occur with the laser lightening/removal :

1) Common temporary side effects of the procedure include, but are not limited to, pain during and/or after
treatment, reddening, some burning sensation, purpura (pinpoint or blotchy bleeding under the skin lasting from a
few hours to several days or more), and ingrown hairs. Swelling and puffiness of the treatment area may occur
especially when on the hands, feet, and facial areas and subsides within a few days with regular ice applications.
2) Temporary bruising may occur, and the area will appear gray or blue-black, and usually will fade in the next 1 or 2
weeks.
3) Blistering, pustules, crusting, and scab formation usually develop within the first few days of treatment and resolve
in 1 to 2 weeks. It is extremely important not to pick or pop any blisters and to follow post-treatment instructions.
4) Other side effects may occur such as a brownish/red darkening of the skin (called hyperpigmentation) or skin
lightening (hypopigmentation). Hyperpigmentation usually resolves in weeks, but it can take up several months to
heal. It is more common in patients with olive, dark, or ethnic skin tones and can worsen if the laser-treatment area
is exposed to sun or tanning which is why the avoidance of sun, tanning, and tanning products is crucial to help the
healing and not worsen the skin appearance. Hypopigmentation can occur in the laser-treated areas, and the pale
areas usually darken or repigment in several months but can be permanent in rare cases.
5) Freckles, birthmarks, or pigmented lesions in the treatment area may be lightened, reduce, or permanently
removed.

6) Textual and/or color changes in the skin can occur and be permanent. There is a chance that after the skin has
healed from the laser treatment, the skin may be raised, uneven, or not smooth, and additional treatment or medical
care may be needed.
7) 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 unremovable.
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.
8) There are risks of unforeseen complications, which can last months, years, or permanently. These are rare, but
possible.
9) Although an infection (bacterial, fungal, and viral) after treatment is unusual, it can occur. Herpes simplex virus
infections around the mouth can occur following a treatment whether you have a history of herpes simplex virus
infections and never have been known to have it. Should any type of skin infection, oozing, or spreading redness
occur, contact the treatment provider immediately for possibly additional medical care and antibiotics, which might
be necessary.
10) There have been reports of hypersensitivity or allergic reactions to the various tattoo pigments from the laser
tattoo treatments especially if the tattoo pigment contained mercury, cobalt or chromium. Upon dissemination, the
ink chemicals or pigments can induce a severe allergic reaction each successive treatment. Noted in some patients
are superficial erosions, bruising, blistering, milia (whiteheads), redness, and swelling which can last up to many
months, years or permanently. There also is a chance of an allergic reaction to any topical ointment, antibiotic,
cream, or sunscreen.
11) Scars are extremely rare but may occur on disruption of the skin’s surface. It is very important to adhere strictly to
all advice and instructions given by the treatment provider to reduce the change of scarring and other side effects.
12) Although laser treatments are effective most of the time, there is no guarantee that the goal or anticipated
results will be achieved and there is a chance that the target does not improve at all or perhaps worsens despite
best efforts to lighten or remove the pigment or ink. Some tattoo ink colors, like white, do not respond well to laser
treatments and tattoos that have flesh tone (or tail, brown, peach) are susceptible to darkening after laser
treatment, especially cosmetic tattoos (eyeliner, lip liner.)
I must comply with the aftercare guidelines for healing, prevention of scarring, and minimizing side effects such as
hyperpigmentation. For 4 months after each laser treatment, I must minimize exposure of the laser-treated skin to
sun (deliberate and incidental to being outside) by avoiding tanning, wearing clothes that block sun, and wearing
SPF 30 or greater and cannot use tanning beds, tanning lamps, and tanning products as such products, creams,
lotions, etc. which may interfere with the healing of the treated area or darken the treated skin

I understand that I must discuss with my physician any prior problems with laser treatments and be completely
honest in divulging my medical history, medications, vitamins, and all natural, herbal, or holistic remedies
(“medications”) that I have taken or plan to take in the six weeks before and after the laser treatments, and during
the laser treatments, because medications may impact the treatments and the laser treatments and/or the
medications may need to be altered, suspended, or stopped.
I understand the importance of divulging my personal experience or history of any of the following because this laser
treatment is contraindicated (cannot be provided) if I have had or current have:

• Currently pregnancy or breastfeeding
• Use of Accutane (Isotretinoin) in the last 6 months Melanoma or any cancer
• Seizure disorders triggered by light
• Chemical or mechanical depilation in the treatment area within 6 weeks of this laser treatment ( may impede healing)
• Hormonal or endocrine disorders such as polycystic ovary syndrome or diabetes
• Systemic illness or an illness localized in the treatment area, for example, but not limited to, lupus, arthritis
• Blood clots or treatment with anticoagulants
• Prone to getting scars or Keloid formations
• Dysplastic nevi in or near the treatment area
• Recent or active infections, abrasions, or skin conditions in or near the treatment area; herpes
• Collagen, vascular or immunosuppressive disorders and immune deficiency including HIV or AIDS
• Hypersensitivity at the treatment area to any agents, solutions, or gels to be used in the treatment, if no alternative exists
• Gold therapy now or at any time in my life

In the event of complications, the physician or his/her designated person may prescribe antibiotics, medications, or
require hospitalization, among other options. I understand that I must contact my laser treatment provider if I have
any questions or concerns and seek emergency medical care immediately if I experience any unusual symptoms.
I consent to photographs, videos, and digital images (“tapings”) being taken before, during, and after the
treatment(s), to help evaluate the effectiveness for medical, scientific, or educational purposes, training,
professional publications or for sales and marketing purposes. I authorize, permit, and approve their use and display
publicly in any form, without my further permission..
I have read this entire document and understand all information presented to me before agreeing to proceed with
laser treatments. The procedure, potential benefits and risks, and alternate treatment options have been explained
to my satisfaction, and I have been given a chance to ask questions which have been answered adequately. Before
and after treatment instructions have been discussed with me. I understand the procedure, accept the risks, and
voluntarily authorize and freely consent to the proposed laser treatments including the administration of medication,
anesthesia, and sedation, if needed. I hereby release the physician, treatment provider, facility, and staff from all
liabilities associated with the laser treatments to be performed on me