LASER TATTOO REMOVAL — consent

Consentimiento y acknowledgment — casillas independientes

1. I have answered all the questions regarding my health and skin correctly and to the best of my knowledge, as I am aware that some ailments and medication can affect healing of the skin and response to the laser. It is my responsibility to ensure that I inform my laser operator if I begin a course of medication.
2. I confirm my tattoo is no older than 20 years old.
3. I understand that LTR is an elective procedure and hereby freely accept all possible risks, complications, side effects that may result from this procedure.
4. I understand that I am responsible to apply numbing cream approximately 1 hour prior to my scheduled appointment. Failing to do so may result in the loss of my appointment.
5. If there is a history of Lupus, Herpes simplex or light sensitivity, I will let my provider know and to take the necessary means to protect myself by taking medication or avoiding therapy as directed.
6. It is my responsibility to follow the appropriate aftercare instructions as explained and written in the postcare instruction that are given after treatment.
7. No absolute guarantee of any kind has been made to me, by either the doctor or staff regarding the procedure, the number of procedures or its final outcome.
8. I have discussed the Procedure, Alternative treatments, Risks for Laser Tattoo Removal and had the opportunity to ask questions with my doctor and/or staff members.
9. The treatment will be performed by a certified Medical Cosmetic Enhancements member.
10. I agree to the photographing of my tattoo and procedure. We may use these photographs for scientific and/or illustrative purposes: I understand that I will not be identifiable in these photos (except for the nature of the tattoo itself).
11. This consent form is valid for all furure laser tattoo removal treatments performed, and I will alert the staff if there are any future changes or my medical history, or if I become pregnant.

Release y firmas

My questions regarding the procedure have been answered satisfactorily. I understand the procedure and accept the risks. I hereby release (Joselin ortega) and (JM studio & spa llc) and __________ (any member of the staff) from all liabilities associated with the above indicated procedure.

• Client/Guardian Signature.
• Date.
• Laser Technician Signature.
• Date.