I hereby authorize Dr. Kaga or staff to perform a laser treatment on me. I understand I may not experience complete results, that it may take multiple treatments, may not respond or improve at all and in some cases, may become worse. I am aware that office policy is that there are no refunds or credit given for dissatisfaction or undesirable results. The procedure may result in the following adverse experiences or risks:

• DISCOMFORT: Moderate to significant discomfort is expected. Some areas are more sensitive than others. Topical, local and inhaled anesthetic options may be available if required. Pain may include the feeling of burning, stinging and radiating pain. Transient texture changes are often noted but usually resolve with time.
• PURPURA/BRUISING/REDNESS/SWELLING: The area may appear to be bruised after treatment. The bruising or purpura will typically fade in 14 days. Short term redness (erythema) of the treated area is common and may occur. There also may be some swelling and/or bruising. Red rash/bumps may appear after treatment. This resolves with time.
• HEMOSIDERIN STAINING: (iron leaking into tissue from blood breakdown) may occur and usually resolves over time, but it may be permanent.
• BLISTERS/SCABS/CRUSTING: Pigmented lesions may crust as part of the healing process. Epidermal crusting may develop over vascular lesions. It is important not to disturb the crusts. May require medication if sensitivity or redness occurs. Crusts will typically slough 7 to 14 days after treatment.
• PETECHIAE OR PINPOINT BLEEDING: Pinpoint bleeding or oozing may develop and can continue up to 2 days post-treatment.
• HYPER/HYPOPIGMENTATION: Skin can develop temporary lightening or darkening after laser treatment. Hyperpigmentation can be worsened with sun exposure. Hypopigmentation usually occurs after multiple treatments. Pigmentary issues typically resolve with time but can be permanent.
• EDEMA AND ERYTHEMA: Swelling and redness often occur, but will subside in 2-5 days and can be reduced with regular ice application.
• ALLERGIC REACTION: Patients who have had a prior allergic reaction to ink during tattoo application may have a similar reaction after laser treatment. Please inform us if you experienced any side effects when your tattoo was applied. This can also happen with laser hair removal. Localized rash with or without redness and/or itching may appear up to 48 hours post-treatment. An anti-histamine can be administered or hydrocortisone can be applied. Symptoms should resolve within a few days. Treatment may result in itching and/or dry skin.
• BURNS/INFECTION: Despite good wound care, pain, swelling, loozing, and fever can indicate an infection. Topical and/or oral antibiotics may be necessary. If signs of infection develop, such as pain, heat, or surrounding redness, please call us. Treatment can result in burning, blistering, or bleeding of the treated areas. If any of these occur, please call us.
• SCARRING: Scarring is a rare occurrence, but it is a possibility if the skin's surface is disrupted. To minimize the chances of scarring, it is important that patients follow all post-treatment instructions provided. Good post-treatment care can help reduce the possibility of scarring.
• PERSISTENCE OF PIGMENTED LESION: Multiple treatments are common, and complete clearing is not always possible.
• DARKENING OF LESIONS/CHANGE IN SKIN COLOR: Lesions will darken post-treatment and will slough 5-21 days post-treatment. During the healing process, there is a possibility that the treated area may become either lighter (hypopigmentation) or darker (hyperpigmentation) in color compared to the surrounding skin. This is usually temporary, but, on a rare occasion, it may be permanent. SUN EXPOSURE TANNING BEDS / ARTIFICIAL TANNING - May increase risk of side effects and adverse events.
• SUN EXPOSURE TANNING BEDS ARTIFICIAL TANNING: May increase risk of side effects and adverse events.
• INCOMPLETE TATTOO REMOVAL/PARADOXICAL DARKENING OR COLOR CHANGE: Multiple treatments are required, and complete clearing is not always possible. Not all ink colors and compositions will respond to tattoo removal treatment. Some tattoo links, including many lighter and skin-tone links, may darken or change color in response to treatment.
• "BLEEDING" OF INK INTO SURROUNDING SKIN: May result in smudging or loss of definition of a tattoo rather than removal.
• UNDESIRABLE HAIR REDUCTION: Hair reduction may occur at treatment sites. This is usually temporary but may be permanent.
• EYE EXPOSURE: Protective eyewear will be provided to you during the treatment. Failure to wear eye shields during the treatment may cause severe and permanent eye damage. For women of childbearing age: By signing below I confirm that I am not pregnant. Furthermore, I agree to keep Dr.Kaga informed should I become pregnant during the course of treatment. For Juliet treatments, I certify that I have had a normal pap smear within the past 6 months. I acknowledge that potential risks of the procedure including possibility that the treatment may not work or make things worse. Possible complications/risks involved with the proposed procedure and subsequent healing period have been discussed as well as alternative treatment options.
• I acknowledge that COVID-19 transmission is a possibility.
• I acknowledge that the service and the facility providing the service will rely on the information provided herein and that I have responded honestly. I agree to update any changes to the information provided herein prior to any future treatments. I acknowledge and understand that this laser treatment is not intended to diagnose, treat, cure or prevent any disease or illness. I hereby voluntarily agree to release the facility providing the service and its owners, agents, and employees from any liability for any injury, loss or consequence that may arise as a result of or in connection to any treatments. I am aware that office policy is that there are no refunds or credit given for dissatisfaction or undesirable results.
• I know that the practice of medicine and surgery is not an exact science and therefore, a reputable physician cannot guarantee results. I acknowledge that no guarantee or assurance has been made by anyone regarding the treatment I have herein requested and authorized. I have been advised that the goal is improvement in my appearance, that imperfections may ensue, and that the results might not live up to my expectations or the goals that have been established. I may be dissatisfied with the results.

BY MY SIGNATURE BELOW, I ACKNOWLEDGE THAT I HAVE READ AND FULLY UNDERSTAND THE CONTENTS OF THIS INFORMED CONSENT FOR LASER TREATMENT AND THAT I HAVE HAD ALL MY QUESTIONS ANSWERED TO MY SATISFACTION.