Informed Consent for Scar and Stretch Mark Treatments Client Name: ________________________________________________________ Date: _______________________ I consent to and authorize Tattoo Undo and Veins Too and their Certified Laser Technicians to perform multiple laser treatments and any other related services on me. The procedure that I plan on having utilizes laser technology for the treatment of scars and stretch marks. As a patient you have the right to be informed about your treatment so that you may make the decision whether to proceed for laser scars and stretch mark(s) treatments or decline after knowing the risks involved. This disclosure is to help to inform you prior to your consent for treatment about the risks, side effects and possible complications related to laser scars and stretch mark(s) treatments. The following risks or problems may occur with laser scars and stretch marks treatment procedures. 1. Rarely, infection, scarring, textural changes, allergic reactions, burns and unforeseen complications may happen and can last up to many months, years or be permanent. 2. Infection following treatment is unusual, but fungal and viral infections can occur. This applies to both individuals with a past history of herpes simplex virus infections around the mouth area. Should any type of skin infection occur, additional treatments or medical antibiotics may be necessary. 3. Purpura (epidermal bruising) or pinpoint bleeding is rare, but can occur following treatment. 4. Compliance with the aftercare guidelines is crucial for healing and the prevention of scarring and hyper-pigmentation. 5. Hyper-pigmentation (skin darkening) and Hypo-pigmentation (skin lightening) is very rare. It is usually transient and resolves within 1-12 months. This can be permanent in rare cases. 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. ACNOWLEDGEMENT: By providing my signature below, I acknowledge that I have read and understand that all pigmented lesion treatment results are different and may or may not work on each person including myself. My body chemistry will determine my results. I understand that there are no guarantees. I feel that I have been adequately informed regarding my pigmented lesion treatments. I hereby freely consent to laser scars and stretch marks treatments and I am willing to have it performed on me. My questions regarding the procedure have been answered satisfactorily. I understand the procedure and accept the risk. I authorize Tattoo Undo and Veins Too to perform multiple laser treatments and any other related services on me. I hereby release Tattoo Undo and Veins Too and their employees from all liabilities associated with laser scars and stretch marks procedure. I also consent to any photos/film taken of me to be used to record my progress and for exampIes and marketing purposes. I understand that exposure of my eyes to the laser light could harm my vision. I must keep the eye protection goggles on at all times while the laser is on. Client/ Guardian Signature: ______________________________________ Date: ______________________ Certified Laser Specialist Signature: _______________________________ Date: ______________________ 8719 East Dry Creek Road, Suite B • Centennial, CO 80112 • [email protected] • www.tattooundoandvienstoo.com • 303.990.0120