I,   Name , authorize and consent to the treatment with the Spectrum Laser System manufactured by Rohrer Aesthetics, Inc. I have been advised by, Tania Honeycutt of the Arctic Medical Center & Spa, of the purported advantages and disadvantages associated with this treatment. (initials)  

I understand that treatment with this laser system varies from patient to patient and that more than 1-treatment may be required. (initials)  

Although rare, adverse outcomes such as hyperpigmentation and/or hypopigmentation (darkening or lightening of the skin), skin texture changes, eyebrow or facial hair folical damage, and trace scarring can occur.   (initials)

No guarantees have been made to me regarding the outcome of the treatment or any improvements in my condition due to the procedure.  (initials)  

I understand that the possible benefits are the reduction and possibly the elimination of unwanted pigmented lesions and/or the removal of ink used for tattoo’s.  (initials)  

Due to the brilliance of the laser light energy used, I agree to wear eye protection to shield my eyes.   (initials)

I have been given the opportunity to ask questions and have received satisfactory answers to those questions.   (initials)  

I hereby authorize the taking of photographs. These photographs will be shared with Rohrer Aesthetics, Inc. and Rohrer Aesthetics may use them in marketing brochures. (initials)  

I hereby indemnify and hold harmless Rohrer Aesthetics, Inc. and all individuals associated with Rohrer Aesthetics, Inc., the physician and/or the treating technician, and all staff members at the office of Arctic Medical Center and Spa from any and all liability, damages, cost and expenses arising from or out of the use of the Spectrum Laser System.  (initials)    

With all of the above information understood, I am choosing to be treated with the Spectrum Laser System.   (initials)