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Laser Tattoo Removal Informed Consent

1. Informed Consent: The purpose of this Informed Consent is to help you decide whether laser tattoo removal ("LTR") cosmetic procedure is right for you and to help you make an informed decision to undergo this procedure. This Informed Consent gives you general information about LTR cosmetic procedures, explains other treatment options, and identifies the benefits, risks, side effects, and possible complications associated with LTR procedures.

2. Laser Tattoo Removal Procedure: The laser that will be used has been cleared for distribution by the FDA for this use, and lasers like this one have been in clinical practice for years. The overall goal is to attempt removal of the tattoo, ink, mark, and lesions or to make the colors or decorative pattern as unrecognizable as possible by lightening the pigment pattern. The number of treatments varies, and Luxury Brow + Skin cannot guarantee a specific amount of treatments or guarantee complete removal. The number of treatments varies depending on several factors, including skin color, ink color (green and yellow are least responsive), ink depth, size, and age of tattoo. Please inform us if your tattoo is older than 20 years old. While we strive for this outcome and use the most advanced laser technology available to achieve an optimal result, this may not occur.

3. Alternative Procedures: Camouflaging with make-up, tattooing over with a second tattoo, abrasive treatments, CO2 laser removal, cutting out/excising the tattoo (with tissue expansion or skin grafting, if needed), or no treatment at all.

4. Not Good Candidates: Generally, you are not a good candidate for LTR procedures if:

  • You have had recent laser or sun exposure
  • You are pregnant or are trying to become pregnant
  • You have an immune-compromised condition

5. Risks and Complications: 

  • There is a risk of eye damage from lasers, which will be minimized by the wearing of protective goggles during laser use.
  • Frosting (a white film) will appear on the skin only after the first treatment.
  • Risk of patchy residual pigment, persistence of tattoo pattern, change or permanent lightening of skin color, change in skin texture, or hair loss/thinning.
  • Blistering and pinpoint bleeding may occur and is normal. You should elevate the treated area above the heart and minimize activity while the area is healing.
  • Pain, discomfort, stinging, discoloration, redness, bruising, swelling, blistering, and crusting are common, but infection is rare.
  • Previous treatment by any other method may increase any or all of these risks.
  • Scarring is a rare possibility.
  • Irregular pigmentation and mild texture changes can occur as a result of laser treatment, but these changes usually return back to "normal" over a period of six months to one year after final treatment.
  • After each treatment, different amounts of fading will occur, ranging from very little to significant amounts during the course of treatment.
  • Despite our best efforts, there remains the possibility that not all of the ink will be removed. Certain colors and certain types of ink may be more difficult to remove, and many may appear darker before getting lighter.

6. Post-Procedure Instructions: Ice lasered area and apply sunscreen when outdoors. Use Aquaphor ointment to protect lasered area.

First Participant's Name

First Name*

Middle Name

Last Name*

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
Parent or Guardian's Email Address

Email*

Confirm Email*
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Client Acknowledgement
I acknowledge that:
The information contained in this Informed Consent was explained to me using terms I could understand, and all my questions and concerns have been answered. After reviewing all the information provided to me about cosmetic procedures and reviewing my health status, I believe I am a good candidate for the LTR procedure.
I confirm that my tattoo is no older than 20 years old.
I understand that LTR is an elective procedure and hereby freely accept all possible risks, complications, and side effects that may result from this procedure.
If there is a history of Lupus, Herpes simplex, or light sensitivity, I will let my provider know and will take the necessary means to protect myself by taking medication or avoiding therapy as directed.
It is my responsibility to follow the appropriate aftercare instructions as explained and written in the aftercare instructions that are given after treatment.
No absolute guarantee of any kind has been made to me regarding the procedure, the number of procedures, or the final outcome.
I have discussed the Procedure, Alternative Treatments, Risks for Laser Tattoo Removal, and had the opportunity to ask questions with my service provider.
I agree to the photographing of my tattoo and procedure.
This consent form is valid for all future laser tattoo removal treatments performed, and I will alert the staff if there are any future changes, including to my medical history, or if I become pregnant.
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*

Middle 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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