Informed Consent for Picolor Pigmentation and Tattoo Treatment

Patient’s Name:
File No.:
DOB:
Mobile Number:
Visit Date:
Registration Time:
Doctor Name:

Picolor Procedure:

The Pico Sure 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.

Prior to the treatment, test spots may be performed. Test spots help to determine effective treatment settings. Tattoos may blister and have pinpoint bleeding for a few days after treatment. Following a pigment treatment, the treated areas may be red, slightly swollen; pigment may darken and slough off in 7-10 days.

The area should be treated delicately following treatment. Do not pick on scabbing/blistering. Multiple treatments may be necessary.

I have been informed that hyperpigmentation (darkening of the skin), and hypopigmentation (lightening of the skin) are possible complications of the procedure and incidence of this occurring are higher for darker skin types      Yes    No

I understand that sun exposure, as well as not adhering to the posttreatment instructions provided to me may increase my chance of complications.

I agree to have before and after pictures taken of the area to be treated:      Yes    No

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 understand and agree that I am financially responsible for the payment I made for that any amount I paid for the sessions or procedures I booked it will only be valid up to 3 months from the date I made the payment. I understand that I need to utilize the sessions or procedures within 3 months period. I agree that my payment made is non-refundable or non-transferable post this period.

I declare that I have read and fully understood all points in this consent and that all of my questions were answered to my satisfaction and I take the full responsibility of my decision in this consent.

 

Patient Name & Signature :   

Doctor/Therapist Name & Signature :   

Witness Name & Signature :     

Parent or Gaurdian Name (if patient is minor) :

Date :

Consent to be photographed and published

I, , consent to be photographed and published on Social media, by while before and after the procedure. I further authorize that the photographs may be published for any purpose and in any form.

Patient Name & Signature :