Healthcare Tattoo Removal Consent Form

HEALTHCARE TATTOO REMOVAL CONSENT FORM

Patient Information

Patient Name:    Date of Birth:    Gender:

Emergency Contact

Insurance Information (if applicable)

Medical History

Are you currently pregnant or breastfeeding? Yes No

Do you have a history of keloid scarring or abnormal wound healing? Yes No

Do you use topical or oral retinoids or have you used isotretinoin in the past 12 months? Yes No

Procedure Details

Treatment Area(s):

Tattoo Age (approx.):    Tattoo Colors:    Estimated Size:

Risks, Benefits, and Acknowledgments

I understand that laser or light-based tattoo removal is intended to reduce or remove pigment but that complete removal cannot be guaranteed. Potential risks and complications include, but are not limited to: scarring, hypopigmentation (lightening of skin), hyperpigmentation (darkening of skin), infection, textural change, incomplete pigment removal, allergic reaction, blistering, and need for additional treatments. Results vary by skin type, tattoo color, depth, age, and individual healing response.

I acknowledge that the provider has explained the anticipated benefits, the expected course of treatment, the estimated number of sessions, possible alternative treatments, and the probable consequences of not proceeding with treatment. I have had an opportunity to ask questions and have received satisfactory answers.

I understand that the treatment area may require multiple sessions spaced over several weeks or months and that adherence to pre-treatment and post-treatment care is required to minimize complications.

Pre-treatment instructions provided include avoidance of sun or tanning, cessation of self-tanning products, and disclosure of recent use of photosensitizing medications. Post-treatment care instructions include wound care, sun protection, and reporting signs of infection.

I consent to the application of topical anesthetic or local anesthetic as deemed appropriate by the provider. I have disclosed any known allergies to anesthetics or components of topical preparations.

Authorizations and Releases

Photography: I authorize the taking of clinical photographs before, during, and after treatment for medical documentation, treatment planning, and quality assurance. I understand photographs may be used for internal education and anonymized case review. I consent: Yes No

Release of Liability: To the fullest extent permitted by law, I release the treating provider and facility from liability for complications which may result from the procedure except for gross negligence or willful misconduct. I understand that additional medical care may be necessary to treat complications and I will follow recommended aftercare.

I acknowledge that no promises or guarantees have been made to me regarding the outcome of treatment, and that the practice of tattoo removal is not an exact science.

HIPAA / Privacy Acknowledgment

I acknowledge that I have been offered a copy of the practice's privacy notice describing the uses and disclosures of my protected health information. I consent to the use and disclosure of my health information for treatment, payment (if applicable), and healthcare operations in accordance with the notice provided.

I authorize the release of medical information necessary to process claims or coordinate care related to the tattoo removal procedure.

Patient Consent Statement

By signing below I certify that I am at least 18 years of age or, if under 18, I am the legal guardian and authorized to consent on behalf of the minor. I have read, understand, and accept the foregoing information and consent to the proposed tattoo removal treatment. I acknowledge that all my questions have been answered to my satisfaction.

Additional Notes

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