State-of-the-art, personalized skin care
from experienced professionals
“A regular skin checkup can literally save your life.” Jennifer Krasnoff, MD

The procedure planned is treatment of a tattoo with the MedLite Q-Switched Nd:Yag Laser using local, topical, or no anesthesia. The purpose of this procedure is to attempt removal of the tattoo or to make the pattern as unrecognizable as possible by lightening the pigment pattern.

Alternative treatment methods include camouflaging with makeup, tattooing over with a second tattoo, abrasive treatments, acid treatments, cutting out (with tissue expansion or skin grafting if needed), or no treatment.I understand that the risk of the procedure include possible pain, bleeding, blistering, infection, scarring, drug reactions and unforeseen complications. Eye injury is possible but highly unlikely, since complete eye protection is provided throughout laser treatment sessions. There is also a risk of persistence of residual pigment, persistence of tattoo pattern, permanent lightening of the skin color, change in skin texture, and hair loss or hair thinning. The risk of scarring, including keloid formation, despite proper treatment, exists in all cases and can be greatly minimized by proper aftercare and prompt treatments by the doctor (within 1 to 3 weeks of the appearance of the scar). Previous treatment by any method may increase any or all of these risks.

I understand that this procedure fails to remove all pigment in some cases, especially with professionally applied tattoos, and may not be effective with certain pigment such as yellow. Laser treatment of white or flesh colored tattoos can cause dark brown/black color change Multiple treatments are generally required. I understand my responsibility for properly fulfilling the appropriate aftercare instructions as explained by the doctor, his/her staff, and/or written instructions provided.

I agree that pre- & post-operative clinical photographs and videos may be taken to monitor my treatment progress and for patient educational purposes. I understand that my identity will be protected.

I certify that I have read and understand the contents of this consent form. I have been given the opportunity to ask the doctor/staff any questions that I have about the procedure, and all of my questions have been answered. The doctor/staff has explained the procedure and its alternatives to me, and I both understand and accept the risks involved in this procedure.

Please download this PDF form to sign.





Petaluma Office
165 Lynch Creek Way
Petaluma, CA 94954
 M-F, 8:00am-5:00pm
(707) 762-5531
Fax: (707) 762-5976



Hercules Office
500 Alfred Nobel Dr., Ste. 245
Hercules, CA 94547
M-F, 8:00am-5:00pm
Open Saturday for aesthetic services
 (510) 741-7418
Fax: (510) 741-7456


Billing office
Fax: 510- 741-7493

At Dermatology Associates of the Bay Area, our board-certified dermatologists serve patients at our Petaluma and Hercules offices. We are committed to the highest standards, and we offer a full range of cosmetic, medical, and surgical dermatology procedures, as well as quality skin care products.

Dermatology Associates of the Bay Area
165 Lynch Creek Way | Petaluma, California 94954 | Phone: (707) 762-5531 | Fax: (707) 762-5976
500 Alfred Nobel Drive, Suite 245 | Hercules, California 94547 | Phone: (510) 741-7418 | Fax: (510) 741-7456