Healthcare PMU Removal Consent Form

Healthcare PMU Removal Consent Form

Patient Information

Patient Name:

Date of Birth:    Gender:

Insurance Information

Medical History

Procedure Description

I hereby authorize the clinician to perform permanent makeup (PMU) removal on the following area(s):

Method(s) to be used (may include one or more techniques):

Number of anticipated sessions:    Estimated interval between sessions:

Risks, Benefits, and Alternatives

The benefits, risks, and possible complications of PMU removal have been explained to me, including but not limited to: incomplete pigment removal, permanent scarring, hypopigmentation or hyperpigmentation, textural changes, infection, prolonged redness or swelling, allergic reaction to topical agents, pain, and the potential need for additional treatments. I understand that results cannot be guaranteed.

Alternatives to the proposed procedure include no treatment, camouflage makeup, or referral for alternative removal modalities. I acknowledge that the clinician has discussed these options with me.

I consent to undergo PMU removal as described above and authorize the clinician to perform the agreed procedures.

I authorize clinical photography for medical records, treatment planning, and documentation. I understand photos may be used anonymously for training or quality assurance unless otherwise restricted in writing.

I consent to the use of topical and/or local anesthetic agents as clinically indicated. I have informed the provider of any known anesthetic allergies.

I understand that additional or alternative techniques may be performed if unexpected findings occur during treatment, and that such decisions will be made in my best clinical interest.

Post-Procedure Care and Instructions

I acknowledge that I have received and understand post-procedure care instructions including wound care, sun protection, and infection signs. I agree to follow instructions and to contact the clinic promptly if I experience concerning symptoms.

HIPAA and Privacy Acknowledgment

I acknowledge that I have been provided with information regarding how my protected health information will be used and disclosed in connection with my treatment. I understand my rights concerning privacy and have the right to request restrictions on certain uses and disclosures.

Acknowledgment of Receipt of Privacy Practices: I acknowledge receipt of the clinic's privacy practices.

Authorization and Certification

By signing below I certify that I am the patient or the authorized legal guardian or representative of the patient. I have read and understand this consent form, all my questions have been answered, and I authorize the performance of the PMU removal procedure and any other related care as deemed necessary by the clinician. I understand I may withdraw consent at any time prior to the procedure.

I release the clinician and clinic from liability for complications that are not due to willful misconduct or gross negligence. I understand that billed charges for services rendered are my responsibility regardless of insurance coverage.

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