Laser Treatment

Name *

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Date of Birth *

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Which service are you looking for? *
Where on the body is your tattoo located? *
How long have you had the tattoo, approximately? *
Appointment *

I UNDERSTAND THE BELOW LIST OF SHORT-TERM EFFECTS AND SKIN RESPONSES AND AGREE TO FOLLOW MATCHING GUIDELINES
Pain – I am aware that during the procedure, the laser pulse may feel like a rubber band snapping the skin and understand that the intensity of this sensation will vary dependent upon pigment and pigment density. I have been informed that, to reduce discomfort, numbing and/or cold packs and/or cool air might be used. *

I agree
Ash-white discoloration and epidermal elevation – I am aware that immediately after laser exposure, a slightly elevated, white discoloration with or without the presence of punctuate bleeding is often observed on tattoos and pigmentation. I understand that very quickly, this phenomenon will be replaced by redness, swelling, and scabs of variable intensity and duration. *

I agree
Crusting – I am aware that multiple pinpoint crusts may appear. I have been informed that antibiotic ointments or healing ointments should be applied. I understand that It is important I do not rub nor pick my skin which may otherwise lead to scarring. *

I agree
Red or purple spots – I am aware that broken capillary blood vessels can occur and may lead to transient “mini-bruising”. I understand that I will need to avoid any sun/UV exposure in that case. *

I agree
Allergic reactions – I am aware that an immediate or delayed allergic reaction may develop due to some broken tattoo pigments or drug reactions. In that case, I understand that I need to contact my treating Physician for instructions. *

I agree
Infection and inflammation – I am aware that, in some cases, inflammatory conditions may develop. I understand that if the treated area becomes itchy, presents oozing, spreading redness and/or is purulent, I need to contact my treating Physician for instructions. *

I agree
*If you have, or had in the past, an allergic reaction to red tattoo dyes, please make sure to inform your physician. You can use the box on the following page to alert them of your previous history.*
For any other reaction not listed herein and occurring in the days following the treatment, I will refer to my treating Physician for additional counseling and guidelines. *

I agree

Please upload a photo of the tattoo you would like removed (in its most current state): *

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My signature certifies that I have duly read and understood the content of this informed consent form, and gave the accurate information as to my health condition. I hereby freely consent to PiQo4 laser treatment. *

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Consent Form

I UNDERSTAND THE BELOW LIST OF SHORT-TERM EFFECTS AND SKIN RESPONSES AND AGREE TO FOLLOW MATCHING GUIDELINES

PRE-TREATMENT COMPLIANCE CHECKLIST