Consent Form Tattoo Removal
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Laser Tattoo Removal
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No Contraindications are present
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Fitzpatrick Skin Type
• • •
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Skin Baseline Exam
• • •
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Skin Baseline Exam: Comment
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Laser Device Used
• • •
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Laser done by
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Anesthesia Used
• • •
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Area Treated 1
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Number of treatments
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Tattoo Colors
• • •
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Size of Tattoo Treated
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ND:YAG 1064 Qswitch spot size
• • •
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Pulse Count
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Laser Energy Used (J/cm2)
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ND:YAG 532 Qswitch spot size
• • •
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Pulse Count
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Laser Energy Used
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Ruby 694nm Spot Size
• • •
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Laser Energy Used
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Pulse Count
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Area Treated 2
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Number of Treatments 2
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Tattoo Colors 2
• • •
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Size of Tattoo Treated 2
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ND:YAG 1064 Qswitch spot size
• • •
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Laser Energy Used
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Pulse Count
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ND:YAG 532 Qswitch spot size
• • •
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Laser Energy Used
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Pulse Count
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Ruby 694nm Spot Size
• • •
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Laser Energy Used
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Pulse Count
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Follow up
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Post Laser Instructions Given
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