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Click ‘Get Form’ to open the tattoo removal consent form in the editor.
Begin by reading the introductory section carefully. This outlines the procedure and potential outcomes, ensuring you understand what to expect.
In the consent section, confirm that you have read and understood the information provided. You will need to check each statement indicating your comprehension of risks and benefits.
Fill in your personal details where indicated, including your name and signature. Ensure that all information is accurate for proper documentation.
Review the photography authorization section. If you agree to have your photos taken for medical purposes, sign and date this section as well.
Finally, double-check all fields for completeness before submitting the form through our platform.
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NEW YORK STATE MEDICAID PROGRAM PHYSICIAN
No bill will be processed for payment without a properly completed consent form. (Refer to Billing Section for completion instructions). NOTE: For
S.D. Admin. R. 44:12:01:13 - Tattoo and saline tattoo removal
A minor may riot be tabooed or have a tattoo removed unless the minors parents or legal guardian have signed a consent form authorizing the tattoo or tattoo
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