LASER CONSENT FORM – Skinfinity Therapeutics

Laser Therapy Consent Form

Name *

First

Last

Date of Birth *

Address *

Address Line 1

City

State

Zip Code

Phone *

Email *

Please upload a photo of your ID *

Click or drag a file to this area to upload.

INFORMED CONSENT

The purpose of this form is to ensure you are able and suitable to have laser tattoo removal.
Please read and be certain you understand the implications of signing this waiver, release and consent form.

Please check each provision in the boxes provided after reading to show that you understand each provision.
Please be aware none of the information given is passed on to any third parties and is kept confidential

IMPORTANT

Prior to any laser treatment it is important that you avoid exposure to sunlight and sun beds for at least 2 weeks and do not apply any fake tanning products for 1 week before treatment.

If you have any of the following please inform your laser technician immediately:

Lupus or other autoimmune deficiency
Pregnant or Breast Feeding
Bleeding abnormalities (Haemophilia)
Taking Anti-coagulants (Plavix, Coumadin,etc.)
Treatment of Acne in the last six months
Keloid or very thick scarring
Inflammatory Skin Conditions (e.g: Psoriasis) or Injuries
Hypo-Pigmentation
Rheumatoid Arthritis "Gold" Therapy
Herpes simplex or fever blisters
Diabetes
Epilepsy
Cancer
HIV / AIDS
Used St John's Wort in the past 3 months
Newly Tanned skin (includes; natural suntan, tanning bed, fake tans) in last 30 days
Waxing/Plucking/Electrolysis/Sugaring within last 6 weeks

I hereby consent to and authorize the staff of Skinfinity Therapeutics/Skinfinity Tattoo Company to perform multiple treatments, Laser procedures, and related services on me. The procedure planned uses laser technology for the removal of tattoos, dark spots, acne scars, stretch marks, and other laser cosmetic procedures. *

This consent form is valid for all future laser treatments performed, and I agree to alert the staff if there are any changes to my health, new medications, or if I become pregnant. *

As a client, you have the right to be informed about your treatment so that you may make the decision whether to proceed for laser tattoo removal/spot removal/carbon facial/and other related laser services, 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. Do you agree and understand? *

POSSIBLE RISKS AND SIDE EFFECTS: By ticking each item, you acknowledge understanding of the possible risk or side effect. *

The possible risks of the procedure include but are not limited to pain, purpura, swelling, redness, bruising, blistering, crusting/scab formation, pin-point bleeding, 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 hyperpigmention) 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.
Texture 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 colour may be un-removable. Because of the immediate whitening of the exposed treated area by the laser, there can be a temporary obscuring of ink, which can make it difficult or impossible to notice a specific colour 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 herpes simplex virus infections in the mouth area. Should any type of skin infection occur, additional treatments or medical antibiotics may be necessary.
Bleeding: Pinpoint bleeding can occur and is common as the treatments progress and the laser is breaking up ink in deeper tissue, and can occur following treatment procedures. Should bleeding occur, a non-adherent cause will be placed on the area.
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 patients are superficial erosions, bruising, blistering, milia, redness and swelling which can last up to many months, years or permanently.

I understand that 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 30 or greater must be used. *

I agree to co-operate with the Pre and Post Care recommendations of Skinfinity Therapeutics while I am under their care, realizing that any lack of co-operation could result in less than optimal results. I agree to inform my technician immediately if any adverse effects occur. *

I understand that multiple treatments will be necessary to achieve 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. *

I certify that I have read the entire informed consent and I agree to all its provisions. I certify that I have had the opportunity to ask questions and these questions have been answered to my satisfaction. I fully understand the treatment conditions and procedure. *

I agree to pay for the above mentioned services (unless expressly stated in my booking information) and understand that there will be no refunds for any performed services. *

I understand that response to treatment varies on an individual basis, and that my results will depend on my immune system and health, and that specific results are not guaranteed. Therefore, in consideration for any treatment I have received, I agree to unconditionally defend, hold harmless and release from any and all liability Skinfinity Tattoo Company, Inc. and Skinfinity Therapeutics, LLC and the individual that provided my treatment, the insured, and any additional insureds, as well as any officers, directors, or employees of Skinfinity Tattoo Company, Inc. and Skinfinity Therapeutics, LLC for any condition or result, known or unknown, that may arise as a consequence of any treatment that I receive. *

I release and freely give my consent and all rights to any photographs taken of me and the tattoo taken in the studio and give consent in advance to their reproduction in print or electronic form. (If you do check the NO box, please advise and remind your Laser Technician and the Tattoo Studio NOT to take any pictures of you and your treatment!) *

By typing my name below, this will serve as my electronic signature: *

Laser Therapy Consent Form

INFORMED CONSENT

Visit Us

HOURS