Laser Tattoo Removal Consent Form Name * First Name Last Name DOB * MM DD YYYY Phone * (###) ### #### Email * Emergency Contact Name * First Name Last Name Emergency Contact Phone * (###) ### #### Skin Type (Fitzpatrick Scale) * Area(s) to be Treated, Age of Tattoo(s), and Type of Ink * Diabetes or Epilepsy? * Yes No Pregnant * Yes No Inflammation or infection of the skin? * Yes No Lack of normal skin sensation? * Yes No Do you scar easily? * Yes No Contact dermatitis or any other skin disease? * Yes No Do you suffer from any heart conditions? * Yes No Do you use a pace-maker or similar device? * Yes No Any allergies? * Yes No Do you have or have ever had any of the following: Auto-Immune Disease Cold Sores Dermatitis / Eczema Diabetes Hemophilia Hepatitis Histamine Reaction HIV/AIDS Keloid (thick) Scars Latex Allergies Seizures / Epilepsy Pregnant Patient Consent * I confirm that the information I have provided is accurate and true at this time. If I choose to proceed with the tattoo removal treatment, I understand that it is my responsibility to notify the clinic of any changes to my health or personal information throughout the course of my treatments. I understand that if I choose to proceed with tattoo removal, I must notify the clinic of any changes to my health or personal details during my treatment plan. I understand that tattoo removal can involve risks such as pain, purpura (purple discoloration), swelling, redness, bruising, blistering, crusting or scabbing, ingrown hairs, infection, and other complications which may last for months, years, or possibly be permanent. I understand that scarring is a possible, though rare, risk. I understand that short-term effects may include redness, mild burning, temporary bruising, or blistering of the treated area. I understand that hyperpigmentation (darkening of the skin) or hypopigmentation (lightening of the skin) may occur, and while usually temporary, these changes can take 3–6 months to resolve. I understand that in rare cases, skin pigment changes may be permanent. I understand that freckle loss or changes in pigmentation may occur as a result of the treatment. I understand that textural or color changes in the skin are possible and could be long-lasting or permanent. I understand that cosmetic and body tattoos may contain pigments like iron oxide or titanium dioxide, which can darken during treatment and may not be removable. I understand that the laser may cause immediate whitening of the skin, temporarily obscuring the ink, and that some colors may turn black and stay that way. I understand that infections are uncommon but possible and may include bacterial, fungal, or viral infections. I understand that cold sores or Herpes Simplex Virus outbreaks can occur, even if I have no prior history of them. I understand that an infection may require further medical treatment or antibiotics. I understand that pinpoint bleeding may occur and additional care may be necessary if it does. I understand that allergic reactions to tattoo ink can occur during treatment, especially with pigments containing mercury, cobalt, or chromium. I understand that allergic reactions can worsen with repeated treatments and may include redness, blistering, bruising, scabbing, swelling, or prolonged irritation. I understand that following post-care guidelines is critical to proper healing and minimizing risks like scarring or pigmentation changes. I understand that I must avoid sun exposure for at least two months after each session. I understand that if I must be in the sun, I should use sunscreen with SPF 25 or higher daily. I understand that multiple treatment sessions will be necessary to achieve noticeable results. I understand that no guarantee or warranty has been provided regarding how much of my tattoo will fade or be removed. I understand that complete removal is not always possible due to how tattoos are designed. I understand that unforeseen equipment issues may result in rescheduling and that I will be notified if possible. I understand that if my appointment is rescheduled due to technical issues, I will not hold the clinic responsible for the inconvenience. I confirm that all of my questions have been answered to my satisfaction. I understand the tattoo removal procedure and accept all risks associated with treatment. I hereby release Nabi Esthetics from all liability related to my tattoo removal sessions. Digital Signature * First Name Last Name Date * MM DD YYYY Thank you!