LASER TATTOO REMOVAL CONSENT FORM

PATIENT INFORMATION:

First Name

Last Name

Date Of Birth

Phone/Mobile

City

Next Of Kin

Kins Contact Number (Phone/Mobile)

MEDICAL HISTORY

Do you have a history of skin disorders or infections?

Yes

Do you have a history of keloid scarring?

Yes

Pregnant or breastfeeding?

Yes

Do you have any other medical conditions?

Yes

Your other conditions

Procedure Description:

I understand that I am receiving laser tattoo removal treatment. Laser tattoo removal is a non-invasive procedure that uses high-intensity laser beams to break down tattoo pigments in the skin. The laser targets the tattoo ink, allowing the body to gradually eliminate the pigments and fade the tattoo.

Benefits and Risks:

I have been informed that the benefits of a laser tattoo removal may include:

Significant lightening or complete removal of the tattoo
Improved appearance of the skin in the treated area

I understand that there are potential risks and side effects associated with a laser tattoo removal, including:

Mild discomfort during the procedure (can be managed with topical anesthesia)
Temporary redness, swelling, or itching of the treated area
Temporary changes in skin pigmentation (lightening or darkening)
Rarely, scarring or textural changes in the skin (typically uncommon and treatable)

Aftercare:

I agree to follow the post-treatment instructions provided by the clinician to ensure the best possible results and minimize any risks. I understand that failure to adhere to these instructions may increase the likelihood of complications.

Consent for Treatment:

I hereby consent to undergo a laser tattoo removal treatment. I acknowledge that the clinician has explained the procedure, its benefits, and potential risks to me. I have had the opportunity to ask questions, and all of my concerns have been addressed to my satisfaction. I understand that the results of a laser tattoo removal can vary, and multiple sessions may be required for optimal results.

Release of Liability:

I release The Abram, its employees, and representatives from any liability associated with the laser tattoo removal treatment, except for cases of negligence or intentional misconduct.

Pictures or Videos will be obtained for medical records. If pictures are used for education and marketing purposes, all identifying marks will be cropped or removed

Initial

I agree that all the above information is true and accurate to the best of my knowledge

Client’s signature: