Tattoo Removal Laser Patch Test Consent Form
Acroma QS Laser Tattoo Removal Patch Test Information
Acroma QS laser tattoo removal is a proven treatment for removing black or dark-pigmented tattoos. The Acroma QS laser cannot remove colour pigments; however, other laser systems available outside of Lumiere Medispa may be able to treat these.
The Acroma QS, an Nd: YAG Q- Switch 1064nm laser, directs laser light energy into the skin where the tattoo pigment is located. This energy passes through the skin's outer surface, called the epidermis, and penetrates the lower layers of the skin, where the tattoo pigment is then shattered into smaller fragments via rapid heat transfer. These fragments are slowly eliminated from the skin over several weeks.
You will require multiple treatments (as many as 10-15 treatments), and the final result can vary from person to person and tattoo to tattoo, depending upon your particular indication, tattoo pigment, age of the tattoo, skin quality, and the degree of correction required.
Before A Laser Tattoo Removal Treatment
You must first attend an assessment and information consultation with one of our Nurses or Aestheticians. Your skin type, expectations, and goals will be assessed and discussed during this time. You will also be provided with the estimated duration and cost of each session or series of sessions.
Patch Test
If you are a qualified candidate, you must undergo several patch tests of Acroma QS laser energy delivered in the indicated area at varying intensity levels. This allows your practitioner to understand how responsive your skin is and helps ensure a safer treatment in the future.
There is a risk that the patch test process could cause an adverse effect, such as those found below in the "Risks and Complications" section of this form.
You must wait at least 24 hours after performing a patch test before receiving a full laser treatment.
Patch Test Process
Your practitioner will cleanse your skin in the treatment area.
You will be required to wear eye protection glasses/goggles during the treatment to protect your eyes from the laser light. It is also advised that you close your eyes during treatment.
Your practitioner will choose an initial low-energy appropriate to the area. They will place the device applicator onto your skin and fire the laser applicator towards the treatment area. They will inspect the skin, and, if there is no visible adverse reaction, increase the energy and repeat the process. This will usually happen several times with several different energy settings, during which your practitioner will constantly assess your skin reaction and endpoints (positive reactive points).
Your practitioner will also assess your comfort levels and adjust the required treatment parameters. It is normal to experience some discomfort within the skin, and some areas may be more sensitive than others.
Post Treatment
We want you to have the best treatment outcomes in the safest possible way. For this reason, we strongly advise that you purchase and use Calecim Professional Serum, an umbilical cord stem cell-based aftercare serum. This reduces your risk of scarring complications and increases the speed of recovery and comfort post-treatment. You will need to apply a light layer of Calecim Professional serum over the whole treatment area twice daily until healed and covered with a loose dressing.
You must also commit to keeping the tattoo protected from the sun with clothing or purchase and use a clinically validated sun protection product. Where applicable, your practitioner will discuss which products will most suit your skin type and condition. You must avoid sun exposure, artificial sun beds, and artificial tanning products in the treatment areas.
It is entirely normal for tattoo pigmentation to become temporarily darker following this treatment. It signifies that the pigment has been shattered and will be gradually cleared by the body.
After this treatment, you may notice a tingle, mild heat sensation, and pink skin colour, which is considered normal. These effects will usually settle on the same day.
Occasionally, bleeding may occur at the treatment site. In this case, your practitioner will apply a dressing, which should be kept covered until dry.
Any blisters should be allowed to deflate naturally and loosely covered to protect them. Should any blisters burst, please get in touch with the clinic for further advice on how to care for the area.
You must contact your practitioner immediately if you have any concerns following a laser tattoo removal treatment. You may require medical intervention from one of our clinic nurses.
Alternative Treatments
Your practitioner will always advise you of the safest and most effective treatment based on your medical history and skin appearance. However, you should also consider the option of no treatment at all. Other treatment options are available to remove skin tattoos, such as other types of laser and surgical skin grafting. Whilst we do not provide alternative treatments at Lumiere Medispa, please discuss these options with your practitioner if you wish to explore alternative options.
Contraindications:
You cannot have an Acroma QS laser patch test if:
You have tanned skin either from UV light exposure or artificial skin tanning products. (No UV-tanned skin for four weeks prior to treatment).
You have a skin type 4, 5 or 6. There is a high risk that natural skin colour could be removed (hypopigmentation).
You have or have a history of malignant (cancerous) skin lesions.
Your tattoo contains high concentrations of iron or titanium dioxide.
You have had roaccutane/Isotretinoin medication in the last 6 months.
You have allergies or intolerance of lidocaine anaesthetic cream (Only if wanting the area numbed prior to treatment).
You have photosensitive epilepsy.
You have an active infection or inflammation near the intended treatment area, including active acne lesions.
You have open wounds in the intended treatment area.
You have an active outbreak of herpes simplex infection (Cold sores) in the treatment area.
You have a history of keloid or raised scarring.
You have uncontrolled diabetes or poor wound healing.
You have blood clotting problems or are taking blood thinning medications.
You are immunosuppressed.
You have a history of post-inflammatory hyperpigmentation.
You have uncontrolled hormonal disorders.
You have a pacemaker.
You think you could be pregnant, are pregnant, or are lactating/ breastfeeding.
Cautions:
You need to tell your aesthetic practitioner if:
You suffer from recurrent bouts of herpes simplex infections, as a laser tattoo removal treatment may encourage an outbreak.
You take photosensitising medications/apply photosensitising skincare.
You use topical retinol or prescription retinoid medications in the treatment area. You must stop using these four days before a laser tattoo removal treatment.
Material Risk (the level of significance you personally apply to the risks, side effects or complications of this treatment within your own circumstances):
As with any medical procedure, this treatment carries the risk of side effects or complications. Discuss these risks with your practitioner to fully comprehend their implications. Consider the risks in relation to your personal circumstances, including your health, lifestyle and career and decide if they are acceptable. If not, discuss alternatives or take more time to decide.
Associated Risks:
Permanent tattoo removal. Although it may seem obvious, you should be aware that laser tattoo removal is permanent, and you should be 100% certain that you no longer want the tattoo.
Discomfort. Laser tattoo removal is uncomfortable. Many patients comment that it can be more uncomfortable than having the tattoo in the first place. Your practitioner will do all they can to make the treatment as comfortable as possible; however, it must be understood that it is a painful procedure. A topical anaesthetic cream can be applied before treatment; however, you must arrive 30 minutes before your appointment and inform the receptionist that you would like this upon arrival. Please note we do not apply anaesthetic cream prior to patch tests.
Skin erythema (skin redness) and heat. This is the most common and likely side effect of your laser tattoo removal treatment. This is related to the rise in internal skin temperature and is normal. It can be managed by keeping the skin cool following your treatment. The heat sensation should subside within a few hours, but it can last longer. Skin erythema will likely last a few days after the treatment.
Swelling, tingling, or tenderness. For a few days after treatment, you may experience slight discomfort (like mild sunburn) and swelling within the skin.
Broken, bleeding skin. When the laser light is absorbed by the tattoo pigment, it causes a shattering effect within the skin, which could cause the skin to break. This could happen at the point of treatment or following the treatment. Should this occur following your treatment, please inform your practitioner immediately for further guidance on how to care for the area.
Bruising welts or numbness. Rarely, some patients may experience bruising, particularly if the skin has broken and bled.
Skin wounds. Laser tattoo removal treatments may result in blisters or skin wounds. If a blister or skin wound develops, it may take 5 to 10 days to heal and, in extremely rare instances, may lead to a noticeable whitening or darkening of the skin or, even more rarely, a scar. Blisters or skin wounds are much more common if you do not follow the recommended avoidance of sunlight, artificial tanning products, UV light exposure, and fluorescent light exposure pre and post-treatment.
Pigment changes. With the laser energy used in the Acroma QS device, there is a small risk of temporary hyperpigmentation (increased pigment or brown discolouration) or hypopigmentation (whitening of the skin). Usually, these pigment effects are temporary and resolve over several weeks or months. Permanent hyperpigmentation or hypopigmentation is rare and may occur in less than one per cent of cases. Using advised skincare products throughout the laser tattoo removal course will reduce this risk. These medical skin care products are important to obtain optimal results and reduce complications.
Scarring. Very rarely, if you have developed a wound and subsequent scar, the scar may become flat and white (hypotrophic) or large and red (hypertrophic) or extend beyond the margins of the injury (keloid). Subsequent treatment or surgery may be required to improve the appearance of the scar. In some cases, the scar may be permanent. Failure to follow pre- and post-treatment care instructions may increase the likelihood of a skin wound or scar.
Infection. Although infection is exceedingly rare, a blister or wound that has formed due to laser tattoo removal treatments may become infected. To avoid infection, contact your practitioner if you ever experience a blister or wound following a laser tattoo removal treatment.
Herpes (cold sores) reactivation. Treatments that create a skin injury, such as laser treatment, carry the risk of an outbreak of herpes (fever blisters/cold sores/shingles) in individuals who already carry the herpes virus. If your tattoo removal treatment is on your face and you have had cold sores before, you should manage this as you would normally, such as using over-the-counter cold sore medication. If you experience these regularly, you may need a prescription for aciclorvir medication to suppress the virus before and after treatments. Please contact your practitioner if you experience a severe outbreak following treatment.
Ghosting. When pigment is removed from a tattoo with a laser, you may be left with an imprint of the original tattoo shape in a skin colour lighter than your natural skin colour. This area may also not tan the same again in the future and may burn easily or leave a lighter outline of the original tattoo.
Dissatisfaction. Not all tattoos, skin conditions, and skin types are the same and, therefore, may not respond in the same way as expected. Your skin’s response may be subject to variation. Although the overwhelming majority of patients who have undergone Acroma QS tattoo removal treatments report a near-complete clearance of dark tattoo pigment, it is a possibility that you may not see an appreciable removal of your tattoo. We will always try our best to help you achieve your expectations; however, you must be aware that, even in these circumstances, we will not refund the treatment.
Photographs:
We need to take photos of the treatment area to document the original condition before treatment begins and to monitor results and potential changes throughout the treatment process. These photos will become part of your medical aesthetic treatment record at Lumiere Medispa.
You have the right to refuse consent for these photographs. However, please be aware that without this consent, we will not be able to treat you for medico-legal reasons.
If we wish to use your photos for any other purpose, we will always seek separate written consent from you. You have the right to refuse this additional use of your photos, and it is not mandatory to consent to any other photo usage to receive treatment.
Informed Consent:
This consent form is not meant to include all possible risks associated with an Acroma QS Laser tattoo Removal treatment, as there are both known and unknown side effects and complications associated with any medical treatment. We have written this consent form to ensure you are fully informed of the procedure, reasons why you may not be able to receive treatment and known risks of an Acroma QS laser patch test.
By signing this consent form, you acknowledge and confirm the following:
Risks and complications
You have discussed the potential risks and benefits of an Acroma QS laser patch test with your practitioner, and all of your questions have been answered to your satisfaction.
You understand that medical attention may be required to resolve any complications associated with your treatment. In most cases, except those in an emergency, you should contact your practitioner for advice/treatment.
Medical History
To the best of your knowledge, you have provided the details of your past medical history and will inform your practitioner if this changes before any future treatments.
You understand that withholding aspects of your medical history could lead to serious physical and mental harm.
Contraindications & Cautions
You are not pregnant or possibly pregnant, lactating or nursing, and you will inform your practitioner if this changes before any future treatments.
Fees & Charges
You understand and agree that all services rendered will be charged directly to you, and you are personally responsible for payment.
You further agree, in the event of non-payment, to bear the cost of collection, court costs and reasonable legal fees, should they be required.
Refunds
Fees charged for treatment are for the delivery of a treatment and the accompanying service, which is inclusive of the following;
-Consultation and assessment
-The provision of information and advice
-The provision of the treatment itself, as described above
-Follow-up appointments and aftercare advice and support as appropriate
Whilst we undertake to provide excellent service, factual, honest and ethical advice, safe, expert treatment in experienced hands and only the best products, we cannot guarantee your results and cannot offer refunds if the results achieved fail to meet your expectations. The successful outcome varies by degree, and how long these effects last varies from one individual to another and cannot be guaranteed.
You understand that whilst you have been advised of a probable result, this should not be interpreted as a guarantee.
You will contact your practitioner if you are unsatisfied with your treatment outcomes.
Aftercare
You have verbally discussed the aftercare required following an Acroma QS Laser tattoo Removal treatment, and you have been informed that you will also receive this via email. You understand the importance of following the post-treatment advice and agree to follow it.
You understand that failure to follow this advice could lead to serious physical and mental harm.
Photograph Use Consent:
You understand that receiving treatment at Lumiere Medispa requires photographs to be taken of the treatment area. These photographs may be taken before, during, and after each treatment and will form part of your legal medical record at Lumiere Medispa. By signing below, you freely give your consent for your photos to be used solely for this medico-legal purpose. If we wish to use your photos for any other purpose, we will always seek separate written consent from you, and you have the right to refuse.
Valid Consent
By signing below, you acknowledge that you have read and understood this consent form and have had the opportunity to discuss any questions you have with your practitioner to your satisfaction. You consent to receive an Acroma QS laser patch test under the terms of this consent form and understand that you have the right not to consent to this treatment and that your consent is voluntary.
