I certify that I am over the age of 18, am not under the influence of drugs or alcohol. I am not pregnant, and I consent to and authorise for one or more treatments of laser procedures to be performed on me today and on subsequent follow up dates. I am aware of the following listed: The possible risks of the procedure include but are not limited to pain, purpura, swelling, redness, bruising, blistering, crusting/scab formation, scarring, ingrown hairs, infection, and unforeseen complications which can last up to many months, years or permanently 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 color change is a rare risk. Loss of freckles or pigmented lesions can occur. Textual 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 (white) 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 be 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 for Lip ink removal can lead to cold sores/ herpes simplex infection. 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 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. 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 outdoors, a sunscreen with SPF 30 or greater will be used. 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 and I understand that complete removal may not always be possible. I will be liable for any damage/loss of property. With this agreement, the operator will be exempted from any subsequent claims, demands, compensation of damages, actions and causes of action arising from the provided service. My questions regarding the procedure have been answered satisfactorily. I understand the procedure and accept the risks. I hereby release the from all liabilities associated with the above indicated procedure. I have read and understand the contents of each paragraph above. I acknowledge this is a contract and that I have received no warranties or guarantees with respect to the benefits to be realized from, or consequences of, the aforementioned procedure(s). I further acknowledge that at the time of signing this consent to this procedure(s), I was of sound mind and capable of making independent decisions for myself. I certify that I have read and fully understand the contents of this form. I understand the risks and alternatives involved in this procedure(s). I have had the opportunity to ask questions
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