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Informed Consent

Laser Tattoo Removal Treatment

ACKNOWLEDGMENT, WAIVER, AND CONSENT TO RECEIVE THE LASER TATTOO REMOVAL PROCEDURE. DO NOT SIGN THIS FORM WITHOUT READING AND UNDERSTANDING ITS CONTENTS. 

1. Laser Tattoo Removal Procedure

We utilize the PiQo4™ & Picoway™ machine for tattoo removal, it is a revolutionary laser that offers a new approach to removing tattoos, pigmentation based on photoacoustic energy.

Laser tattoo removal works by breaking up the ink in the skin so that the body can gradually dispose of the ink particles. However, some colors have historically been more difficult to treat with standard laser systems than others. Using four different wavelengths, we can more effectively treat a rainbow of tattoo ink colors compared to older lasers that only offered two wavelengths. Combining both pico and nano technology, we can break down the ink more efficiently and works better on stubborn inks. We treat a larger spot size at once, reducing the length time of treatments and penetrating the skin more deeply than other lasers, while being safer for the skin.

2.  What to expect:

Immediately after treatment, there should be a ‘slight frosting’ on the area that is treated. Redness and swelling at the treatment site can occur and may last up to two hours or longer. Pinpoint bleeding may also occur.

After your first session, your tattoo should appear slightly faded. Typically it requires six to ten sessions to obtain the optimum result, but the number of sessions you’ll need largely depends on the depth of the tattoo, the types and colors of ink used, the color of skin to be treated, and the types of lasers used to eradicate it.

A few more important points to keep in mind:  

  • Tattoos that are less than a year old are challenging to remove.
  • Fading is generally slower for tats located further down the arm or leg (where blood supply is weaker).
  • White ink can be tricky, and green/yellow/purpul ink is notoriously difficult to remove.
  • Professional tattoos can be much more difficult to remove than Amateur tattoos.

Your skin needs time to heal properly, we recommend clients wait 6-8 weeks in between treatments, and getting a tattoo removed too early can increase chance of side effects. 

 

3. Risks and Side Effects:

• DISCOMFORT/PAIN – Some discomfort and/or pain may be experienced during treatment.

• ASH-WHITE discoloration and epidermal elevation – immediately after laser exposure, a slightly elevated, white discoloration with or without the presence of punctuate bleeding is often observed on tattoos and pigmentation. Very quickly this phenomenon is being replaced by redness, swelling and scabs of variable intensity and duration

•  CRUSTING – multiple pinpoint crusts may appear. Antibiotic ointments or healing ointments should be applied. It is important I do not rub nor pick my skin which may otherwise lead to scarring

•  RED OR PURPLE SPOTS – broken capillary blood vessels may lead to transient “mini-bruising”. Sun avoidance is essential in that case

•  ALLERGIC REACTIONS – an immediate or delayed allergic reaction may develop due to some broken tattoo pigments or drug reactions. In that case, I need to contact my treating Esthetician for instructions

• REDNESS/SWELLING/BRUISING – Short term redness (erythema) or swelling (edema) of the treated area is common and may occur. There also may be some bruising.

• HYPOPIGMENTATION / HYPERPIGMENTATION: (Changes in skin Color): – During the healing process, there is a slight possibility that the treated area may become either lighter (hypopigmentation) or darker (hyperpigmentation) in color compared to the surrounding skin. This is usually temporary, but, on a rare occasion, it may be permanent. Patients with dark skin are more likely to experience hypopigmentation (lightening of the skin) due to the way the laser interacts with pigment in the skin. 

• WOUNDS – Treatment can result in burning, blistering, or bleeding of the treated areas.

 • INFECTION – In some cases, inflammatory conditions may develop. If the treated area becomes itchy, presents oozing, spreading redness and/or is purulent, please call our office (212)256-9777.

• SCARRING – Scarring is a rare occurrence, but it is possible. Patients with a history of keloid scarring may develop complications and may want to avoid PiQo4 treatments.To minimize the chances of scarring, it is IMPORTANT that you follow all post-treatment instructions.

 

4. Pre-Procedure Instructions

  • No sun exposure, tanning beds and sunless tanning cream for 4 weeks prior to treatment. Sun exposure decreases the effectiveness of the laser treatment and can increase the chance of posttreatment complications.
  • Use a broad spectrum UVA/UVB sunscreen with an SPF of 30 or higher. Apply to the treated area every 2 hours when exposed to the sun and it is recommended to make this a part of your skin care routine.
  • Remove all makeup, creams or oils prior to treatment. 

 

5. Post-Procedure Instructions

  • Clean the treated area at least twice a day with cold/warm water and mild soap, and then pat the area dry. 
  • Apply a thin layer of topical Steroid (e.g. Betamethasone dipropionate) or Hydrocortisone 1% to the treated tattoo to decrease erythema/inflammation after cleaning the area for 5 to 7 days. 
  • Avoid sun exposure to the treated area. Use sunblock 30-50 (physical blocker with zinc and titanium oxide). Apply to the treated area every 2 hours when exposed to the sun and it is recommended to make this a part of your skin care routine.
  • Discomfort may be relieved by using cool gel packs or acetaminophen.
  • If blistering occurs, apply Anti-biotic oitment twice a day for 7 days.
  • During healing process, the skin may form a thin layer of scab. If crusting/scabbing occurs, do not rub or pick on the area. Apply Aquaphor ointment or other moisturizer to the treated area 2-3 times a day. Keep the area moist and let the crusting/scabbing resolve on its own.
  • Do not enter swimming pools or hot tubs until treated areas are healed. 
  • Drink 8 to 10 glasses of water to encourage drainage of ink to the lymphatic system. 

 

I hereby authorize Bared Monkey MedSpa Inc. and all its affiliated companies and the trained, licensed staffs in this practice to perform the laser tattoo removal procedure on me. I understand that I will require several treatments to obtain an optimum result and the tattoo clearance outcome may vary with each individual and acknowledge that it is impossible to predict how I will respond to the treatment.



Pre and post-care instructions have been discussed and are completely clear to me. 

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


I acknowledge there are possible complications/risks involved with the proposed procedure and subsequent healing period, including pigmentary changes, scarring and changes to skin texture. I am aware that careful adherence to all advised instructions will help reduce this possibility.


I confirm that I am not pregnant and do not intend to become pregnant anytime during the course of treatment. Furthermore, I agree to keep Bared Monkey MedSpa Inc. and all its affiliated companies and staff informed should I become pregnant during the course of treatment.


I acknowledge photographic documentation may be taken.


 

I have read and understood all information presented to me, and I have been given an opportunity to ask questions before signing this consent. I acknowledge and accept the risks inherent in the laser tattoo removal procedure. I voluntarily assume the risk of possible complications and side effects which may arise from the laser tattoo removal treatment set forth herein; and any of my heirs, executors, representatives or assigns hereby release Bared Monkey MedSpa Inc. and all its affiliated companies from any and all claims, liabilities for personal injury, and property damages of any kind sustained while on the premises, during the treatments set forth herein by any employees or representatives of Bared Monkey MedSpa Inc. and all its affiliated companies. 

April 1, 2023

 


First Patient's Name

First Name*

Last Name*

Phone*
First Patient's Date of Birth*
First Patient's Signature*
Second Patient's Name

First Name*

Last Name*
Second Patient's Date of Birth*
Third Patient's Name

First Name*

Last Name*
Third Patient's Date of Birth*
Fourth Patient's Name

First Name*

Last Name*
Fourth Patient's Date of Birth*
Fifth Patient's Name

First Name*

Last Name*
Fifth Patient's Date of Birth*
Sixth Patient's Name

First Name*

Last Name*
Sixth Patient's Date of Birth*
Seventh Patient's Name

First Name*

Last Name*
Seventh Patient's Date of Birth*
Eighth Patient's Name

First Name*

Last Name*
Eighth Patient's Date of Birth*
Ninth Patient's Name

First Name*

Last Name*
Ninth Patient's Date of Birth*
Tenth Patient's Name

First Name*

Last Name*
Tenth Patient's Date of Birth*
Patient's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Ethnicity
Please specify your genetic origin:
African American
Asian
Caucasian
Hispanic
Mediterranean
Middle Eastern
Native American
Other
Females Only
Are you pregnant?*
No
Yes
N/A
Are you planning pregnancy during the course of your treatments?*
No
Yes
N/A
Medical and Surgical History
Do you have any of the following medical conditions? (please check all that apply)
Active Severe or Cystic Facial Acne
Open facial wound or lension
Metal stents in the treatment area
Implants
Migraines
Bell's palsy
Hemorrhagic or bleeding disorders
Active or local skin disease
Autoimmune Disease
Epilepsy
Herpes or Cold sores
Diabetes
Rosacea
Skin cancer
Psoriasis/Eczema
Gold Theraphy
History of bleeding coagulopathies
Do you have any natural or artificial sun exposure in the past 4-6 weeks?*
No
Yes
Do you have any application of self - tanners within the past 2-3 weeks*
No
Yes
Do you use any photosensitive herbal preparations (St John's Wort, Ginkgo Biloba, etc...) or aromatherapy?*
No
Yes
Do you have any inflammatory skin conditions (dermatitis, active acne, etc...)?*
No
Yes
Any presence or history of active cold sores or herpes simplex virus:*
No
Yes
Do you have infection, skin laceration or scarring on treatment site?*
No
Yes
Do you have active or previous cancer (currently on chemotherapy or radiation)?*
No
Yes
Do you have medical history of keloids or poor wound healing?*
No
Yes
Do you intake of isotretinoin within the past year?*
No
Yes
Do you have immunocompromised conditions (for example: uncontrolled diabetes)?*
No
Yes
Do you have Bleeding coagulopathies or usage of anticoagulants?*
No
Yes
Do you have Gold salts (as part of rheumatoid arthritis treatment)?*
No
Yes
Any presence of double tattoos (camouflage tattoo over an undesired first tattoo)?*
No
Yes
Any Injections, fillers or implants on treatment site within the past 3 months?*
No
Yes
Any laser skin resurfacing treatment, Microdermabrasion, Chemical Peels, Ablative treatment in the past 6 weeks?*
No
Yes

Please list all medications you are currently taking in the 6 months and/or other consideration (if NONE please notate): *

Please list any known allergy? (If NONE, please notate) *
Skin Typing:

Please answer the following questions by selecting the number which BEST describes you. 

Eye Color:*
0. Light color
1. Blue, gray or green
2. Hazel/Light brown
3. Dark brown
4. Black
Natural Hair Color:*
0. Sandy red
1. Blond
2. Chestnut or dark blond
3. Brown
4. Black
Your natural skin colour (unexposed area)*
0. Reddish
1. Pale
2. Beige and olive
3. Brown
4. Dark Brown
If you stay in the sun too long?*
0. Painful, redness, blistering and peeling
1. Blistering followed by peeling
2. Burn, mild peeling
3. Rare burn
4. Never had burns
Do you turn brown after several hours of strong sun exposure?*
0. Never
1. Seldom
2. Sometimes
3. Often
4. Always
To what degree do you turn brown?*
0. Hardly or not at all
1. Light color tan
2. Reasonable tan
3. Tan very easily
4. Turn brown quickly
How does your face react to the sun?*
0. Very sensitive
1. Sensitive
2. Normal
3. Resistant
4. Never have a problem
How often do you tan?*
0. Never
1. Seldom
2. Sometimes
3. Often
4. Always
When was your last tan?*
0. +3 months ago
1. 2-3 months ago
2. 1-2 months ago
3. A few weeks ago
4. A few days ago
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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