I authorize Dr. Zimmerman/Dr. Lee and staff to perform PiQo4™ laser on me in an effort to improve Tattoos (older than 6 months) or other.
I consent to the administration of advisable topical / injectable anesthesia and I have been informed on potential risks and complication of the anesthesia used.
Pre and post-care instructions have been discussed and are completely clear to me.
I understand that there is a rare possibility of side effects or serious complications post treatment, including pigmentary changes and scarring. I am aware that careful adherence to all advised instructions will help reduce this possibility.
I understand that sun exposure or tanning of any sort is not aligned with the pre and/or post-care instructions and may increase the chance for complications.
I understand that tattoo clearance may vary with each individual and acknowledge that it is impossible to predict how I will respond to the treatment.
I understand that the procedure may not be effective on certain pigments and that multiple treatments are required.
I consent to photographs being used for medical education or publication with applied discretion and not revealing my identity.
I agree to review the laser pre-treatment compliance checklist below along with my Physician and bring accurate and updated data, to the best of my knowledge.
I understand the below list of short-term effects and skin responses and agree to follow matching guidelines:
Pain – during the procedure, the laser pulse may feel like a rubber band snapping the skin which level will vary per pigment intensity. To reduce discomfort, numbing and/or cool air might be used.
Ash-white discoloration and epidermal elevation – immediately after laser exposure, a slightly elevated, white discoloration with or without the presence of punctuate bleeding is often observed on dark tattoos. Very quickly this phenomenon is being replaced by redness and swelling that might be minimized via cooling and which may last 3 to 7 days.
Crusting – multiple pinpoint crusts may appear. Antibiotic ointments or healing ointments should be applied. It is important I do not rub nor pick my skin which may otherwise lead to scarring.
Red or purple spots – broken capillary blood vessels may lead to transient “mini- bruising”. Sun avoidance is essential in that case.
Allergic reactions – an immediate or delayed allergic reaction may develop due to some broken tattoo pigments or drug reactions. In that case, I need to contact my treating Physician for instructions.
Infection and inflammation – in some cases, inflammatory conditions may develop. If the treated area becomes itchy, presents oozing, spreading redness and/or is purulent, I need to contact my treating Physician for instructions.
Please answer the following questions to the best of your abilities:
My signature certifies that I have duly read and understood the content of this informed consent form and gave the accurate information as to my health condition. I hereby freely consent to PiQo4™ laser treatment.