Informed Consent for Laser Tattoo Removal

I, consent to and authorize Glyn Uren to perform multiple treatments,  of laser procedures on me.

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 knowing the risks involved. This disclosure is to help to inform you prior to your consent to 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, 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.

• Short term effects may include reddening, mild burning, temporary bruising or blistering. A brownish/red darkening of the skin (known as hyperpigmentation) or lightening of the skin (known as hypopigmentation) may occur. This usually resolves in weeks, but it can take up to 3-6 months to heal. Permanent colour change is a rare risk. Loss of freckles or pigmented lesions can occur.

• Textual and/or colour changes in the skin can occur and can be permanent. Many of the cosmetic tattoos and body tattoos are made with iron oxide pigments. Iron oxide can turn red-brown or black. Titanium oxide and other pigments may also turn black. This black or dark colour  may be un-removable. Because of the immediate whitening of the exposed treated area by the laser, there can be temporary obscuring of ink, which can make it difficult or impossible to notice a specific colour change from the tattoo removal process.

• Bleeding: Pinpoint bleeding is rare but can occur following treatment procedures, should bleeding occur, additional treatment may be necessary.

• Allergic Reactions: There have been reports of  hypersensitivity to the various tattoo pigments during the tattoo removal process especially if the tattoo pigment contained Mercury, cobalt or chromium. Upon dissemination, the pigments can induce a severe allergic reaction that can occur with each successive treatment. Noted in some patents are superficial erosions, bruising, blistering, redness and swelling which can last up to many months, years or permanently.

• Compliance with the aftercare guidelines is crucial for healing, prevention of scarring, and hyper-pigmentation. Aftercare guidelines include avoiding the sun for 2 months after the procedure. If it is necessary to be in the sun, a sunscreen with SPF 25 or greater must be used.

• I understand that multiple treatments will be necessary to achieve results. And confirm that No guarantee, warranty or assurance has been made to me as to the results that may be obtained, or any number of sessions confirmed or implied. Complete tattoo removal is not always possible as tattoos were meant to be permanent.

• If you have had any other form of tattoo removal treatment that has resulted in dis-colouring or scarring then you must be aware that the laser treatment may result in further scaring and may prove ineffective.

ACKNOWLEDGMENT:

            My questions regarding the procedure have been answered satisfactorily. I understand the procedure and accept the risks. I hereby release Glyn Uren and the establishment where treatment took place from all liabilities associated with the above procedure. I have been given, read and understand the information above.

I consent to audio and visual filming via CCTV for the duration of my stay at Red’s and for Red’s to use video and audio material for safety and security reasons.

I confirm that I have been told that laser removal is not successful for all and that I may not achieve the fading or complete removal desired and have read and fully understood this consent form

By signing this consent form, you are irrevocably giving permission to Reds Tattoo Parlour employees to take and use photographs, video and voice recording. This is completely voluntary and up to you.  Your consent to the use of the photographs and videos is for forever.  You will not receive compensation for the use of your image likeness, appearance, and voice now or in the future. Reds Tattoo Parlour may use the photographs and video for advertising purposes, including use on web pages.