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Laser Tattoo Removal Consent Form and Patient Pre and Post Protocol
This form is designed to give you information needed to make an informed choice about Laser Tattoo removal. Although Laser Tattoo Removal is effective in most cases, no guarantee can be made that you will benefit from the treatment. I, _____________________________ understand that several treatments may be needed to obtain the desired level of improvement. Tattoo removal will be done in stages with repeated treatments of intervals of 4-8 weeks. Sometimes a tattoo will not completely clear but become lighter. Also, it is important that you be aware that tattoos can worsen, though that is rare. Potential Side Effects
Pain: Bruising Swelling Blisters or Scabs Infection Hyper pigmentation Hypo pigmentation Scarring Tattoo Persistence or Worsening Actual Side Effects
Crusting Blood Blisters Allergic Reaction to antibiotic cream Transient Hyper pigmentation in dark skinned people By providing my signature below, I acknowledge that I have read and understand all the information written above and feel like I have been adequately informed of my alternative treatment options, the risks of the proposed Laser Tattoo Removal and the risks of treating and not treating my condition. I hereby freely consent to the Laser Tattoo Removal to be performed and authorize the taking of clinical Photographs if needed to document my response and process to treatment. Patient Signature________________________________ Print Name _____________________________________ Witness Signature _______________________________ Print Name _________________________________________ CosMedica Specialty Laser Spa 6160 Sherry Lane, Suite 110 Dallas TX 75225 214.206.1788 LASER TATTOO REMOVAL PRE AND POST PROTOCOL
Contraindications to Laser
Pregnancy Aspirin, Motrin, Aleve Photosensitive Meds Active Sun exposure Herpes, pre-medicate with Valtrex 1gm BID Pre Treatment
Free initial Consultation Cost estimate of fees Informed Consent Anesthetic Cream applied 1 ½ hours prior to laser procedure Comfortable Clothing Remove Jewelry Goggles on Post Treatment
Antibiotic Cream (avoid Neosporin) Bandaging Post OP supplies given Written Post OP instructions Return Appointment I _________________have read and fully understand all information presented to me
for the PRE and POST treatment instructions for LASER TATTOO REMOVAL before
consenting to treatment.
Signature: _______________________________________________ Date: __________ Print name: ______________________________________________ Date: __________ Witness signature: _________________________________________Date: __________ Print name: ______________________________________________ Date: __________ CosMedica Specialty Laser Spa 6160 Sherry Lane, Suite 110 Dallas TX 75225 214.206.1788

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