Informed voluntary consent to the laser removal procedure

As I promise, here is the Client form for Laser Removal Procedure I’m using in my studio. Just copy that to Microsoft word or in any other program and correct it.

Client Form for LaserR Procedure

Click on this link and you will download it to your device.

And here is the same

On the basis of Federal Law No. 323-FZ “Public Health Protection in the Russian Federation” of November 21, 2011

You, as a client, have the right to receive information about your condition and procedure in order to decide whether or not to carry out this procedure, knowing the possible risks and health hazards. This information is provided in order to better inform you before you give or do not give your consent to this procedure.

Full name:
Date of Birth:
Address:
Phone number:

I tell you reliable facts about my health, medications taken, medical procedures carried out, and past diseases:

Allergic reactions:
Bad habits:
Medications:
Chronic diseases:
Infectious diseases:

I confirm that I was informed about the progress of the procedure.

I give my consent to the anesthesia, the method and the use of drugs at the doctor’s discretion. I am informed about the main benefits and complications of anesthesia that can

manifest itself in the form of various allergic reactions (anaphylactic shock, angioedema, fainting, collapse) and post-injection hematomas.

I understand that there may be side effects to the agents used during the anesthesia and the procedure. In this case, I will not have claims to the center and will make every effort to eliminate the consequences of such unforeseen reactions.

I realize that there may be pain during the procedure – pain, burning, cutting, tingling, numbness, other unpleasant sensations, as well as reactions to the procedure in the form of temporary swelling, hematoma, bruising, hyperemia, allergic reactions.

I plan my affairs after the procedure taking into account possible reactions (redness, swelling, bruising, as well as individual reactions).

I have the opportunity to ask any questions about the planned procedures, alternative treatments, risks and health hazards associated with the upcoming

procedures.

The information received is sufficient for me to give this informed and informed consent to the laser removal procedure.

I give my consent to photography and video shooting, realizing that these photos will remain the property of the permanent makeup Studio. It has been explained to me that in any subsequent use of these photographs by the clinic, my name will not be mentioned and it will be difficult to recognize me by using the closure of parts of the face or body.

Features of the recovery period and possible complications.

1. The immediate reaction of the body to laser exposure may include: hematomas, edema, hyperemia and pain in the area of laser exposure for 24-72 hours.
2. Among the complications should be separately identified those that are associated with the failure of the doctor’s recommendations. These include infection of the laser exposure area when personal hygiene is not observed, skin pigmentation in the event of excessive insolation in a solarium or in the sun immediately after the procedure, inflammation caused by a visit to a bath, sauna, or physical therapy immediately after laser exposure.
3. The lack of effectiveness of the procedure. Since efficiency also depends on

individual characteristics of the body, lifestyle, bad habits, chemical

pigment composition, the amount of pigment introduced into the skin.

4. There is the possibility of changing any existing color of artificial pigment under the influence of laser radiation. This is connected with the chemical composition of the artificial pigment, its physical properties, the presence of mixing several types of pigment, and the various absorptive capacities of laser radiation. To predict the color change under the influence of laser radiation is impossible.
5. Some colors of artificial pigments reflect most of the laser radiation with a wavelength of 1064 nm and 532 nm and using ND-YAG laser to destroy these pigments is difficult or almost impossible. Such colors are white, yellow, solid, orange, blue, green, a mixture of pigments containing white.
6. The effectiveness of the procedure depends on the chemical composition of the artificial pigment, its physical properties, depth, quantity, prescription of application to the skin, the characteristics of local tissues in the place of removal of the pigment. It may require a large number of procedures for the destruction of the artificial pigment and may enhance its elimination. The absence of scarring cannot be predicted with absolute accuracy, as it depends on the characteristics of tissues in the area of removal of artificial pigment, the nature and volume of artificial pigment, individual characteristics of the patient’s body response to injury, genetic predisposition to the formation of hypertrophic and keloid scars.

7. I am aware and agree that upon the occurrence of various circumstances

like festering wounds, trauma extraction artificial pigment during the rehabilitation period, an individual’s genetic predisposition and other circumstances unspecified here may not be expected from the procedure cosmetic result with intact skin with no artificial pigment. Perhaps the formation of hyperpigmentation or hypopigmentation in place of the laser exposure, non-absorbable hypertrophic scars – have the appearance of whitish traces located below the level of the surrounding skin, hypertrophic scars – have the appearance of raised above the skin red scars, keloid scars – have the appearance of large, highly raised above the surrounding skin red, extending over the boundaries of the scarring itself.

I confirm that this document was read by me and explained to me and its content is clear to me. I received, read, explained and understood the memo on the recommended behavior in the post-procedural period.

I am warned that contraindications for laser tattoo or tattoo removal are:

• poor blood clotting;
• diabetes;
• a tendency to form keloid scars;
• colds, fever;
• oncology;
• skin diseases in the acute stage;
• herpes inactive form;
• AIDS, hepatitis;
• pregnancy, breastfeeding;
• mental disorders, epilepsy;
• high blood pressure;
• alcohol intoxication, as well as alcohol intake a few days before and after the procedure;
• known hypersensitivity to laser exposure;
• known hypersensitivity to lidocaine or local anesthetics from the amide group;
• children are not allowed to perform the procedure.

I understand that the possible contraindications listed above, as well as those not mentioned here, can lead to complications and additional, therapeutic, diagnostic procedures, which may require me to spend time and money, possible release from work. The center is not responsible in case of complications if I did not inform or did not know about my

contraindications, but gave my consent to the procedure.

I undertake to adhere to and follow all recommendations before and after the procedure, such as:

• It is not recommended to use make-up for 12 hours after the procedure.
• Avoid prolonged exposure to the sun, ultraviolet rays.
• It is not recommended to use the sauna or bath for 3 days after the procedure.

I confirm that I have been informed:

– on the course of the procedure for my deliberate decision.

– I had the opportunity to ask questions before the procedure and get

comprehensive information.

I have read the plan of the laser removal procedure, the peculiarities of the recovery period, possible complications, I am fully aware of the content and purpose of this document, I give my consent to carry out the laser removal procedure and I undertake to implement all the recommendations received.

In pursuance of requirements of the Federal law “On personal data” No. 152 – FZ of 27.07.2006.

I agree with the processing of my personal data to take into account my personal characteristics in order to the optimization of the quality of services, obtaining the necessary recommendations, maximum discounts on the next services. I agree to receive information via SMS, e-mail, telephone calls. This consent is issued without limitation of its validity. By personal data I mean any information relating to me as the subject of personal data, including surname, name, patronymic name, phone number, passport data and other information provided by the current legislation of the Russian Federation. By processing personal data I mean the collection, systematization, accumulation, storage, clarification (update, change), use, distribution (including transfer), depersonalization, blocking, destruction and any other actions (operations) with personal data.

I hereby confirm that I have read the following procedure for revoking the consent to the processing of personal data: in the case of a written revocation of this consent by me, the operator is obliged to stop its processing and destroy my personal data within a period not exceeding three working days from the date of receipt of this revocation.

Notes: ___________________________________________________________________________

Full name: ________________________________________________________________________

Signature: _____________________ «____»_______________ 20___.

Date of visit	Notes	Signature