Picolaser Consent Form

Full Name Of Person Getting Tattoo Removal

ATTENTION:
Picolaser laser removal is not reccomended for patients with the following:

CHECK ALL THAT APPLY:

Are hypersensitive to light in the near infrared wavelength region

Take medication which is known to increase sensitivity to sunlight

Have seizure disorders triggered by light

Take or have taken oral Isotretinoin, such as Accutane��, within the last six months

Have active localized or systemic infection, or an open wound in area being treated

Have a significant systemic illness or an illness localized in area being treated such as lupus.

Have common acquired nevi that are predisposed to the development of malignant melanoma

Have active herpes simplex in the area being treated

Are receiving or have received gold therapy

Precautions: Have any suspicious skin lesions or known history of keloid scarring.

READ AND CLICK THE BOX:

The Picolaser laser produces an intense burst of light that is absorbed by the pigmented lesion or tattoo ink. All personnel in the treatment room, including me, will wear protective eyewear to prevent eye damage from this intense light.

The sensation of the laser light on skin is uncomfortable and may feel like a slight pinprick or the sensation of heat. These sensations may last for a few hours.

Tattoos may blister and have pinpoint bleeding immediately and for a few days after treatment

I have been informed that hyperpigmentation (darkening of the skin), and hypopigmentation (lightening of the skin) are possible complications of the procedure.

I understand that sun exposure, before or after treatment, as well as not adhering to the post treatment instructions provided to me may increase my chance of complications.

Some adverse reactions may include blistering, scabbing, crusting, pustules, burns, erythema, edema and scarring.

Following a facial treatment, the treated areas may red, bronzed, slightly swollen and rarely may develop an acne-like breakout. Your skin may become very dry and flaky. Pigment may darken for a few days. These conditions may last a few hours up to a few days.

I have informed the laser operator if I have any permanent cosmetic ink. (We do not treat cosmetic tattoos, as they may turn gray or green.)

The area should be treated delicately following treatment. Multiple treatments may be necessary, and there is no guarantee that all ink or all pigment will be removed.

I have read and understood all information presented to me, and I have been given an opportunity to ask questions before signing this consent.

I hereby indemnify and hold harmless Rohrer Aesthetics, Inc. and their employees, the treating technician, staff and all entities including but not limited to Keepsake Custom Tattoo, Inc. from any and all liability, damages, cost and expenses arising from or out of the use of the Picolaser.

Patient Name:

Pico Laser Consent Form

ATTENTION:
Picolaser laser removal is not reccomended for patients with the following:

CHECK ALL THAT APPLY:

Precautions: Have any suspicious skin lesions or known history of keloid scarring.

READ AND CLICK THE BOX:

FOLLOW THESE STEPS!!
To upload your ID

Step 1. Click the choose file button below
Step 2. Click take photo or upload photo from device

Signature

Pico Laser Consent Form

ATTENTION: Picolaser laser removal is not reccomended for patients with the following:

CHECK ALL THAT APPLY:

Precautions: Have any suspicious skin lesions or known history of keloid scarring.

READ AND CLICK THE BOX:

FOLLOW THESE STEPS!!*To upload your ID*

Step 1. Click the choose file button belowStep 2. Click take photo or upload photo from device

Signature

ATTENTION:
Picolaser laser removal is not reccomended for patients with the following:

FOLLOW THESE STEPS!!
To upload your ID

Step 1. Click the choose file button below
Step 2. Click take photo or upload photo from device