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Laser Tattoo Removal Consent Form

I consent and authorize the staff at laser luxury to perform laser procedures and related services on me. The procedure planned uses laser technology for the removal of tattoos.  

        As a client, you have the right to be informed about your treatment so that you may make the decision whether to proceed for laser tattoo removal or decline after knowing the risks involved. This disclosure is to help to inform you prior to your consent for treatment about the risks, side effects and possible complications related to laser tattoo removal. 

  • Typically tattoo pigment reduction requires at least 9 to 12 treatments.
  • The treatments are generally at least 8 to 10 weeks apart. Closer intervals do not increase the reduction of pigment.
  • Topical anesthetic is recommended. The cream must be applied 24 hours before the treatment and can be sent home with you after the first treatment.

 The following problems may occur with tattoo removal treatment:

  • The possible risks of the procedure include but are not limited to pain, purpura, swelling, redness, bruising, blistering, crusting/scab formation, ingrown hairs, infection, and unforeseen complications which can last up to many months, years or permanently. There is a risk of scarring and or bleeding, pinpoint bleeding is rare but can occur.
  • Short term effects may include reddening, mild burning, temporary bruising or blistering. A brownish flash red darkening of the skin known as hyperpigmentation or lightening of the skin known as hyperpigmentation may occur. This usually resolves in weeks, but it can take up to six months or more to heal. Permanent color change is a rare risk. Loss of freckle or purple pigmented lesions can occur.
  • Textural and or color changes in the skin can occur and can be permanent period many of the cosmetic tattoo and body tattoos are made with iron oxide pigments. Iron oxide can turn red dash 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.
  • Infection: although infection following treatment is unusual, bacterial, fungal and viral infections can occur. Herpes simplex virus infections around the mouth can occur following a treatment. This applies to both individuals with a past history of herpes simplex virus infections and individuals with no known history of herpes simplex virus infections in the mouth area. Should any type of skin infection occur, additional treatments or medical antibiotics may be necessary.
  • Allergic reactions: there have been reports of hypersensitivity to various tattoo pigments during the tattoo removal process especially if the tattoo pigment contains mercury, cobalt or chromium. The pigments can induce a severe allergic reaction that can occur with each successive treatment. Some patients can have superficial erosions, bruising, blistering, milia, redness and swelling which can last up to many months, years or permanently.
  • Compliance with aftercare guidelines is crucial for healing, prevention of scarring, and hyperpigmentation. Aftercare guidelines include avoiding the sun for two months after the procedure. Even with mild sun exposure a sunscreen of SPF 25 or greater must be used, or keep the area covered.
  • Triple antibiotic ointment must be used during healing for at least 4-7 days after the procedure or longer if any irritation occurs. 
  • Multiple treatments will be necessary to achieve desired results. No guarantee, warranty or any assurance has been made to me ask the results that may be obtained. Complete touch of removal is not always possible as tattoos were meant to be permanent.

        ACKNOWLEDGEMENT: my questions regarding the procedure have been answered satisfactorily. I understand the procedure and accept the risks. I hereby release Laser Luxury and the staff from all liabilities associated with the above indicated procedure. 

I also give consent for my credit card to be charged $25 in the event of a missed appointment or cancelation/rescheduling within 24 hours of my appointment.



I Agree

May 5, 2025


First Client's Name

First Name*

Last Name*

Phone*
First Client's Date of Birth*
First Client's Information

Where is the tattoo on your body?
Have you had previous laser tattoo treatments?*
No
Yes

How many previous treatments?
First Client's Signature*
Second Client's Name

First Name*

Last Name*
Second Client's Date of Birth*
Second Client's Information

Where is the tattoo on your body?
Have you had previous laser tattoo treatments?*
No
Yes

How many previous treatments?
Third Client's Name

First Name*

Last Name*
Third Client's Date of Birth*
Third Client's Information

Where is the tattoo on your body?
Have you had previous laser tattoo treatments?*
No
Yes

How many previous treatments?
Fourth Client's Name

First Name*

Last Name*
Fourth Client's Date of Birth*
Fourth Client's Information

Where is the tattoo on your body?
Have you had previous laser tattoo treatments?*
No
Yes

How many previous treatments?
Fifth Client's Name

First Name*

Last Name*
Fifth Client's Date of Birth*
Fifth Client's Information

Where is the tattoo on your body?
Have you had previous laser tattoo treatments?*
No
Yes

How many previous treatments?
Sixth Client's Name

First Name*

Last Name*
Sixth Client's Date of Birth*
Sixth Client's Information

Where is the tattoo on your body?
Have you had previous laser tattoo treatments?*
No
Yes

How many previous treatments?
Seventh Client's Name

First Name*

Last Name*
Seventh Client's Date of Birth*
Seventh Client's Information

Where is the tattoo on your body?
Have you had previous laser tattoo treatments?*
No
Yes

How many previous treatments?
Eighth Client's Name

First Name*

Last Name*
Eighth Client's Date of Birth*
Eighth Client's Information

Where is the tattoo on your body?
Have you had previous laser tattoo treatments?*
No
Yes

How many previous treatments?
Ninth Client's Name

First Name*

Last Name*
Ninth Client's Date of Birth*
Ninth Client's Information

Where is the tattoo on your body?
Have you had previous laser tattoo treatments?*
No
Yes

How many previous treatments?
Tenth Client's Name

First Name*

Last Name*
Tenth Client's Date of Birth*
Tenth Client's Information

Where is the tattoo on your body?
Have you had previous laser tattoo treatments?*
No
Yes

How many previous treatments?
Parent or Guardian's Email Address

Email
Your signed waiver will be sent to the email address provided here and is available for download for three days via URL attachment.
Client'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(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 Information

Where is the tattoo on your body?
Have you had previous laser tattoo treatments?*
No
Yes

How many previous treatments?
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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