Laser Pigmentation Removal Consent Form

Your permission is necessary before commencing any treatments. The permission form is intended to be a tool to ensure that you have been informed about your procedure, the risks and benefits, and to provide you with a chance to ask questions.

I understand that the success of pigmentation removal varies greatly depending on the age and concentration of pigment. Most commonly 2—12 treatments are necessary to remove the pigment. I understand that there is no guarantee that the procedure will remove all the pigment. Compliance with the aftercare guidelines is crucial for healing, prevention of scarring, and hyper-pigmentation.

I understand that my skin will be extremely sensitive to sunlight following the procedure. I agree to refrain from tanning for 2 weeks prior and 4 weeks following the treatment. Maximum SPF should be worn at all times. I understand that exposure of my eyes to light could harm my vision. I must keep the eye protection goggles on at all times.

Some possible side effects include, but are not limited to:

1) There is a risk of scarring.  

2) Short term effects may include reddening, mild burning, temporary bruising or blistering. Hyper-pigmentation (browning) and Hypo-pigmentation (lightening) have also been noted after treatment

3) Infection: Although infection following treatment is unusual, bacterial, fungal and viral infections can occur. Should any type of skin infection occur, additional treatments or medical antibiotics may be necessary.

4) Bleeding: Pinpoint bleeding is rare but can occur following treatment procedures.

I have read and understand this agreement and all my questions have been addressed and answered to my satisfaction. I consent to the terms of this agreement.