Tattoo Removal Consent
Consent Information
This consent form is designed to give you the information you need to make an informed decision about whether or not to undergo laser treatment of a decorative tattoo with the RevLite® Q-Switch Laser (Laser). The purpose of this procedure is to attempt removal of the tattoo or to make the decorative pattern as unrecognizable as possible by lightening the pigment pattern.
Alternative treatment methods include camouflaging with make-up, tattooing over with a second tattoo, tissue destruction (with mechanical abrasion, topical products or ablative lasers), cutting out (with tissue expansion or skin grafting if needed), or no treatment at all.
Multiple treatments, ranging from 6 - 22, are required for maximum fading or clearing depending on the amount of ink, depth of ink pigment and other factors. Amateur tattoos typically require fewer treatments. Professional tattoos, cover-ups and tattoos on patients with darker skin types often require additional treatments.
Immediately after treatment, tattoos usually whiten, which fades in about 20 minutes. Swelling, redness and tenderness in the treatment area typically resolve within a few hours or a few days. Blisters, crusts and scabs may develop within 24-72 hours, which may last for 1-2 weeks. The treated area may be pink or pale after the scab separates. Increased pigmentation and/or loss of skin pigmentation in the treated area are common and are usually temporary. Complete healing is usually takes 4-6 weeks after treatment. The treated skin must be fully healed prior to subsequent laser treatment.
Results are affected by many factors including individual skin characteristics, type of tattoo ink and color, and body location. Individual response to treatments varies and improvement may not be seen after each treatment. No guarantees can be made that a specific patient will benefit from treatment or achieve any level of improvement from tattoo laser treatment.
Test spots may be performed with the laser prior to treatments. Lack of an adverse reaction with test spots does not ensure that side-effect, adverse reaction or complication will not occur with treatments.
Possible risks, side-effects and complications of laser treatments include, but are not limited to:
Discomfort and pain during treatment and after treatment. Discomfort may last for a few hours to several days.
Temporary redness and swelling. Cold compresses are recommended for 15 minutes every hour to help reduce swelling and the risk of blistering.
Blistering, burns, and scabbing may also occur. Scabs/flaking pigment should not be picked or pulled off and should kept moist with bacitracin ointment and an adhesive bandage until healed.
Bleeding, pin point red spots, and bruising. Bleeding may last up to a few days. Pinpoint red spots typically fade gradually over 1-2 weeks.
Undesired skin pigmentation changes such as hypopigmentation (skin lightening) or hyperpigmentation (skin darkening or discoloration) may occur. These pigment changes typically resolve in three to six months, but in rare cases may be permanent. Use of a full strength sun block (SPF of 30 or greater) after treatment is required to help minimize these risks.
Undesired skin texture changes.
Skin fragility or easy bruising following laser treatments.
In rare instances, infection can occur. If the area looks infected (honey colored crust, oozing, or spreading/increasing redness), you experience unusual discomfort or bleeding, or your temperature becomes elevated, please call our office immediately.
Recurrent viral infections such as herpes simplex (cold sores, genital herpes) or varicella (shingles) may be activated by laser treatments. The physician or treating health care provider must be notified if you have a history of these conditions prior to treatments and a prescription strength medication may be prescribed to help prevent reactivation or a breakout of these viral infections.
Scarring is rare, but can occur despite proper laser treatment. It is seen most often in patients with a predisposition to abnormal scarring, such as a history of keloids or other abnormal raised scars.
Tattoo removal may not be effective on certain pigments, particularly yellow, or may fail to remove all pigment, especially with professional applied tattoos. This may result in persistence of the tattoo pattern (“ghosts”) or patches of residual pigment.
The color of the tattoo may change during the course of treatments as certain pigments are removed.
Laser treatment of white or flesh colored tattoos can cause darkening such as brown or black discoloration, alter their appearance and make them more noticeable.
Hair follicles in the treated area may be permanently affected with any laser treatments, resulting in reduced or no hair growth. Consent to undergo laser treatments constitutes the acceptance of the possibility of reduced hair growth in the treated areas. Hair follicles can grow at angles to the skin and it is possible to affect hairs adjacent to treatment areas.
Permanent makeup in the treatment area may be altered unintentionally. The physician or treating health care provider must be notified prior to treatment if you have this in or near the treated area and do not want them to be altered.
Risk of accidental eye injury if struck by a laser beam. Although eye injury is possible, it is unlikely as laser safety precautions and eye protection are always used throughout all laser treatments.
Inconvenience to the patient during the recovery phase.
The risks of laser use may not be fully known and RSMD, Medical Aesthetics is not responsible for any laser risk or unforeseen complication not yet discovered or not commonly known.
Patients with darker skin types have an increased risk of complications such as hypopigmentation, hyperpigmentation, blistering, scarring, and more variable results.
Consent to laser treatments is also consent to the administration of any related treatments that may be deemed necessary or advisable for these procedures. This includes, but is not limited to: local anesthetic such as topical anesthetics (e.g., benzocaine/lidocaine/tetracaine cream or ointment) or injectable anesthetics. Topical anesthetics applied to the skin can be absorbed into the blood. The risks, side effects and complications of anesthetics include, but are not limited to: skin irritation (itching or redness), lightheadedness, rapid heart rate, visual disturbance, tongue numbness. Patients must inform the physician or treating health care provider immediately if experiencing any of these symptoms. There are rare reports of serious complications of lidocaine/anesthetic toxicity including seizures and death. Toxicity may occur when too much anesthetic is administered. Therefore, RSMD, Medical Aesthetics will only use anesthetic medication in the most sensitive areas. Any known allergy to lidocaine or anesthetics must be disclosed to the physician or treating health care provider prior to treatment. The physician or treating healthcare provider must be informed of any inflammation, injury or open skin in the treatment area or any such problems prior to treatments at all visits.
Patients with the following conditions may not receive laser treatments: history of abnormal raised scarring or keloid formation; pregnancy or lactation, history of seizures, tanned skin, tanning bed use or active sun exposure four weeks prior to treatment.
Certain conditions require caution with laser treatments, and may preclude a patient from receiving treatment: poor healing (due to diabetes or other conditions); a personal or family history of skin cancer (such as melanoma); autoimmune disease; use of photosensiting medications (such as doxycycline, minocycline) or a photosensitive disorder (such as Lupus); history of migraine headaches. It is the patient's responsibility to consult with their personal physician prior to having pigmented lesions treated with laser if they have pigmented lesions that have changed (e.g. enlarged, itched or bled) or if there is a personal or family history of skin cancer. The results of that consultation must be given to RSMD, Medical Aesthetics and the physician or treating health care provider must be notified by the patient of these conditions prior to treatments.
Patient Acknowledgements
I have not had active sun exposure or been in a tanning bed for at least four weeks prior to laser treatments, or used self-tanning products for at least two weeks prior to laser treatments.
I Acknowledge
I have fully disclosed all of my medical history. I understand that it is my responsibility to inform and update RSMD, Medical Aesthetics' physicians and health care providers of any change in my health status and medical history at all visits. All information provided to RSMD, Medical Aesthetics is, to the best of my knowledge, true and correct.
I Acknowledge
I consent to be photographed. Photographs shall be part of the medical record and may be used for educational purposes.
I Acknowledge
I understand that this procedure is considered cosmetic, and is not covered by health insurance. RSMD, Medical Aesthetics will not bill my insurance for this treatment. I understand that my insurance may or may not cover treatment of any complications should they arise. I am responsible for paying the quoted fee for every treatment.
I Acknowledge
I hereby waive, release, discharge any and all claims and agree to indemnify, defend and hold harmless Dr. Small, the medical staff, specific technician, and RSMD, Medical Aesthetics, its members, employees, and affiliates for any injury, loss, expenses, or damages of any nature which may arise or be alleged as a result of my treatments, including that caused solely or in part by the fault of the above-named parties.
I Acknowledge
I am an adult of at least 18 years of age. My signature below certifies that I have fully read this consent form and understand the information provided to me regarding the proposed procedure. I have been adequately informed about the procedure including: the potential benefits, limitations, alternative treatments, and I have had all questions and concerns answered to my satisfaction. I understand and accept the risks, side effects and possible complications inherent in undergoing laser treatments. I consent and authorize Dr. Rebecca Small, a physician assistant, or trained Registered Nurse of RSMD, Medical Aesthetics to perform laser treatments. This consent shall apply to all subsequent laser treatments. If I have any questions, problems, reactions or other concerns related to treatments, I will contact RSMD, Medical Aesthetics at (831) 475-1077. If the office is closed or I do not receive a prompt response, I will go to the nearest urgent care facility or emergency room.
I Acknowledge
I understand that no guarantees or promises can be made or have been made that the condition for which I am seeking treatment will be improved or reduced, and there is a chance that they may be worsened. I also understand that multiple treatments may be required.
I Acknowledge
By signing below, I certify that I have fully read and agree to adhere to the pre-treatment and post-treatment instructions with each appointment. I understand that failure to carefully follow these instructions may affect my treatment outcome and increase the likelihood or severity of complications. Any applicable paragraphs were stricken before I signed. I also state that I speak, read and write English.
I Acknowledge
Laser Tattoo Removal Pre & Post Treatment Instructions
Prior to Treatment
Refrain completely from tanning beds and direct sun exposure for 4 weeks prior to each treatment and for the duration of your treatments. Avoid using sunless tanning products for 2 weeks before each treatment. Treatments will be cancelled and the cost of that treatment forfeited if your skin is tanned.
Use sunscreen daily with SPF 30 or greater for the duration of your treatments.
Discontinue use of glycolic and Retin-A containing products 1 week before treatments.
Do not use medications that causes photosensitivity (including, such as: doxycycline, minocycline) for at least 72 hours prior to Laser treatments.
If you have a history of herpes (oral cold sores, genital) or shingles, in the treatment area start your anti-viral medication (Valtrex, acyclovir) as directed for 2 days prior to treatment and continue for 3 days after treatment.
After Treatment
Immediately after treatment, ice the treated area for fifteen minutes every 1-2 hours or as directed. The area may feel warm, appear swollen, reddish or bruised. Blistering or scabbing can occur particularly if ice is not applied as directed, and will generally heal in one to two weeks. Typically, within a day any discomfort should disappear.
If the skin is irritated (without scabs or bleeding), apply sunscreen SPF 30 or greater daily. You may put a bandage of gauze and paper tape over the area if desired, but this is not needed.
If the tattoo is in an area prone to abrasion, e.g. where pants or bra strap contact skin, keep tattoo dressed (as above) until fully healed and the skin is no longer shiny
If blistering, crusting or scabbing develops contact RSMD immediately and use Bacitracin, Hydrabalm, or Aquaphor daily to keep the area moist. Place a bandage over the area (as described above) and replace every day until all scabs are fully healed to prevent infection.
Do not pick any crusted or scabbed areas, as it may interfere with healing and cause scarring.
Keep the area clean with gentle cleansing. Do not rub with a washcloth or towel; pat dry.
Avoid irritants such as glycolic and Retin-A products, toners, exfoliants, astringents, or other products that cause irritation for 1 week following treatment. Once irritation has resolved, you may exfoliate in the treatment area.
Avoid direct contact with hot water (e.g., hot tubs, saunas) for 1 week following treatment.
Avoid activities that can cause flushing for 72 hours after treatment or as instructed by provider including: consuming alcohol, or tanning. If you experience swelling after treatment, avoid activities until swelling resolves.
Avoid sun exposure and tanning for 4 weeks following each treatment. Use sunscreen daily with SPF 30 or greater for the duration of your treatments.
Light exercise (e.g., walking, gentle yoga) is fine 24 hours after treatment. Avoid strenuous exercise (e.g., Crossfit, hot yoga, hot pilates, running) for 72 hours after treatment.
If surfing/swimming, cover tattoo with bacitracin and gauze and place a tegaderm (or other waterproof bandage) on top of the gauze with at least 1 inch of adhesive around the gauze.
Changes in skin color may last several months and rarely, may be permanent.
Please contact RSMD Medical Aesthetics at (831) 475-1077 if you have any questions. If problems arise after hours please contact your nearest urgent care facility.