The procedure planned is the treatment of a decorative tattoo with a Q-switch Nd:YAG 1064 and/or 532 mm, using topical or no anesthesia. 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. 

As a patient, you have the right to be informed about your treatment so that you may make the decision whether to proceed for light energy Tattoo removal or decline after knowing the risks involved. This disclosure is to help inform you prior to your consent for treatment about the risks, side effects and possible complications related to light energy Tattoo removal.

I understand that the risks of the procedure include possible pain, bleeding, burning, reddening, infection, scarring, purpura, swelling, redness, bruising, blistering, crusting/scab formation, ingrown hairs, drug reactions and unforeseen complications which can last up to many months, years, or permanently. There is also the risk of patchy residual pigment, persistence of tattoo pattern, change or permanent lightening of skin color, change in skin texture, or hair loss or thinning. Previous treatment by any method may increase any or all of these risks. 

I understand that this procedure fails to remove all pigment in some cases, especially with professional applied tattoos and may not be effective on certain pigments. A brownish/red darkening of the skin (hyperpigmentation) or a lightening of the skin (hypopigmentation) may occur especially in darker skin tones. This usually resolves in weeks but it can take up to 3-6 months to heal. Permanent color change is a rare risk. Loss of freckles or pigmented lesions can occur. Laser treatment of white or flesh colored tattoos can cause dark brown/black color change. Textural and/or color changes in the skin can occur and can be permanent. Because of the immediate whitening of the exposed treated area by the light energy, there can be a temporary obscuring of ink, which can make it difficult or impossible to notice a specific color change from the tattoo removal process. 

THERE ARE ADDITIONAL RISKS ASSOCIATED WITH REMOVING PERMANENT MAKEUP! Many of the cosmetic tattoos are made with iron oxide pigments. Iron oxide can turn red-brown or black when contacted with a laser. Titanium oxide and other pigments may also turn black. This black or dark color may be un-removable. We will do a test spot and then monitor the area before proceeding with total removal. With signing this document, you aknowledge that you agree to this procedure regardless of being notified of said risks.

Please also consider the additional risks associated with removing pigmented lesions.

If test spots are necessary in order to determine the correct course of treatment in cases such as permanent makeup, keloids, etc, you agree not to hold Second Chance Laser Tattoo Removal LLC/DBA Second Chance Cosmetic Laser Studio liable for any adverse reactions.

Although infection following treatment is unusual, bacterial, fungal and viral infections can occur. Herpes simplex virus infections around the mouth can occur following a treatment. This applies to both individuals with a past history of herpes simplex virus infections and individuals with no known history of herpes simplex viruses in the mouth area. Should any type of skin infection occur, additional treatments or medical antibiotics may be necessary. If you have a history of herpes simplex virus in the treated area, we recommend preventative therapy.

Pinpoint bleeding is rare but can occur following treatment procedures. Should bleeding occur, additional treatment may be necessary. 

Allergic reactions have been reported due to hypersensitivity to the various tattoo pigments during the tattoo removal process especially if the tattoo pigment contained Mercury, cobalt or chromium. Upon dissemination, the pigments can induce a severe allergic reaction that can occur with each successive treatment. Noted in some patients are superficial erosions, bruising, blistering, milia, redness and swelling which can last up to many months, years or permanently. If I have an allergy to the ink once tattoo removal begins to break up ink, I understand that treatment would be at my own expense.

Compliance with the aftercare guidelines is crucial for healing, prevention of scarring, and hyperpigmentation. Aftercare guidelines including avoiding the sun for 2 months after the procedure. If it is necessary to be in the sun, a sunscreen with SPF 50 or greater must be applied. I understand my responsibility for properly fulfilling the appropriate aftercare instructions as explained by the Second Chance Laser Tattoo Removal LLC/DBA Second Chance Cosmetic Laser Studio Specialist.

I understand that multiple treatments will be necessary to achieve desired results. No guarantee, warranty, or assurance has been made to me as to the results that may be obtained. Complete tattoo removal is not always possible as tattoos were made to be permanent. 

The procedure is generally considered cosmetic and is not covered by insurance. I understand that I am responsible for all costs of treatment(s). 

Occasionally, unforeseen mechanical problems may occur and your appointment will need to be rescheduled. We will make every effort to notify you prior to your arrival to the office. Please be understanding if we cause you any inconvenience. 

I have been asked at this time whether I have any questions about this procedure and I do not have any further questions. I understand the procedure, accept the risks, and request that this procedure be performed by Second Chance Laser Tattoo Removal LLC/DBA Second Chance Cosmetic Laser Studio. I hereby release Brittany Hart (Owner), Second Chance Laser Tattoo Removal LLC, DBA Second Chance Cosmetic Laser Studio, and Dr. Stephanie Herrera (medical director) from all liabilities associated with the above indicated procedure.