Informed Consent for Laser Tattoo Removal 

I, ____________________________________ consent to and authorize Atlantic Laser Tattoo Removal and members of its medical staff to perform multiple treatments, laser procedures and related services on me.  The procedure planned uses laser technology for the removal of tattoos. 
As a patient 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:

The following problems may occur with the tattoo removal system.
1.	The possible risks of the procedure include but are not limited to pain, swelling, redness, bruising, blistering, crusting/scab formation, ingrown hairs, infection, and unforeseen complications which can last up to many months, years or permanently.
2.	There is a risk of scarring.  Scarring happens but is uncommon.  Scarring can be permanent.
3.	Short term effects may include reddening, mild burning, temporary bruising or blistering.    A brownish/red darkening of the skin (known as hyperpigmention) or lightening of the skin (known as hypopigmentation) may occur at times up to 3-6 months, years or permanently following treatment.  Loss of freckles or pigmented lesions can occur.  
4.	Textual changes in the skin can occur and can be permanent.  
5.	Infection: Although infection following treatment is unusual, bacterial, fungal and viral infections can occur.  Should any type of skin infection occur, additional treatments or medical antibiotics may be necessary.  
6.	Bleeding: Pinpoint bleeding is rare but can occur following treatment procedures.  Please follow the basic after-care instructions to prevent the risk of infection.
7.	Allergic Reactions: Upon dissemination, the pigments can induce a severe allergic reaction that can occur with each successive treatment.  This may occur if you are allergic to the ink in your tattoo, or to the topical antibiotic (Neosporin or similar) applied after the laser procedure.  
8.	I understand that exposure of my eyes to light could harm my vision. I must keep the eye protection goggles on at all times. 
9.	Compliance with the aftercare guidelines is crucial for healing, prevention of scarring, and hyper-pigmentation. 
Occasionally, unforeseen mechanical problems may occur and your appointment will need to be rescheduled. We will make every effort to notify you prior to your arrival to the office. Please be understanding if we cause you any inconvenience.  We occasionally may use photographs taken before or after treatments in order to assess, promote, train, or improve our services.  These will be used anonymously and only include the treated area and not associated with any particular patient.  

ACKNOWLEDGMENT:
My questions regarding the procedure have been answered satisfactorily.  I understand the procedure and accept the risks.   I hereby release Atlantic Laser Tattoo Removal, its staff, and medical director from all liabilities associated with the above indicated procedure.  

Client/Guardian Signature						Date_______________
Certified Laser Specialist 						Date_______________