Consent Form

I authorize Pua Manu MedSpa _______________________________ to perform laser on me for treatments of skin resurfacing, benign pigmented lesions or tattoos (older than 6 months)

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 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 cold packs 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 tattoos and pigmentation. Very quickly this phenomenon is being replaced by redness, swelling and scabs of variable intensity and duration

• 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 Pua Manu Medspa for instructions

• For any other reaction not listed herein and occurring in the days following the
  treatment, I will refer to Pua Manu Medspa for additional counselling and guidelines

PiQo4 tattoo removal is designed to make tattoos lighten with the use of advanced laser technology. The PiQo4 laser is able to eliminate almost every tattoo because it uses four different wavelengths. This allows the laser to target and destroy every popular tattoo ink color on every skin tone.

PiQo4 (tattoo treatment) treated over hair will turn white. The hair follicles may become damaged. They are located at the same level as tattoo ink color(s) therefore it will remove the pigment from both tattoo and hair. There is a 50% chance that the hair may not grow back.

I understand the above statement and agree to be treated with PiQo4 for tattoo removal which may or may not be treated over hair.

For any other reaction not listed herein and occurring in the days following the treatment, I will refer to my treating Physician for additional counselling and guidelines

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 and bring accurate updated data, to the best of my knowledge

CHECKLIST:

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 laser treatment