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Access Laser Center Intake Form

Registration / Consent Form

Gender

Informed Consent for Laser Tattoo Removal

 

I, ____________ , consent to and authorize Access Laser Center to perform multiple treatments, laser procedures and related services on me. The procedure planned used 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:

 

•  The possible risks of the procedure include but are not limited to: pain, purpura, swelling, redness, bruising, blistering, crusting/scab formation, ingrown hairs, infection, an 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 (hyperpigmentation) or lightening of the skin (hypopigmentation) may occur. This usually resolves itself in weeks, but can take up to 3-6 months to heal. Permanent color change is a rare risk. Loss of freckles or pigmented lesions can occur.

 

•  Textural and/or color 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 color may be un-removable. Because of the immediate whitening of the exposed treated area by the laser, there can 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 HSV infections in the mouth area. Should any type of skin infection occur, medical treatment may be necessary

 

•  Bleeding: Pinpoint bleeding is rare but can occur following laser treatments. 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 can occur with each successive treatment. Noted in some patients are superficial erosions, bruising, blistering, milia, 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 hyperpigmentation. 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 higher must be used.

 

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

 

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.

 

Acknowledgement:

My questions regarding the procedure have been answered satisfactorily. I understand the procedure and accept the risks. I hereby release the provider and Access Laser Center from all liabilities associated with the above indicated procedure.

Photo Consent Form

 

I, _______________ , grant permission to Access Laser Center for the use of the photographs or electronic media as identified below in any presentation of any kind whatsoever. I understand that I may revoke this authorization at any time by notifying Access Laser Center in writing. The revocation will not affect any actions taken before the receipt of this written notification. Images will be stored in a secure location and only authorized staff will have access to them. They will be kept as long as they are relevant and after that time destroyed or archived.

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Late/Cancellation Policy

I understand that a 24 hour notice is required to cancel and/or reschedule my appointment or a $25.00 fee will be added to my account.

I understand that it is my responsibility to arrive to my appointment 15 minutes early to ensure enough time for treatments, questions, etc. I understand if I arrive late to my appointment, the laser tech will determine if scheduling for that day will allow for the treatment to take place.

Access Family Pharmacy and Access Laser Center prohibit any child under the age of thirteen to be left in the vehicle on company property or in the lobby unattended. Children are also not allowed to be present in the laser room during procedures. For more information regarding this state law, please visit TN.gov, TCA Code 55-10-803.

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