Sydney Laser Tattoo Consent Form

Name *

First Name Last Name

Date of Birth *

Date

Phone Number *

Area Code Phone Number

Email *

example@example.com

Address *

Street Address

Street Address Line 2

Suburb State

Post Code

In the past 14 days have you felt unwell or had any symptoms of Covid-19 (such as fever, coughing, shortness of breath), returned from overseas, had any contact with a confirmed or suspected case of Covid-19? *

YES NO

Are you under the influence of drugs? *

YES NO

Have you taken aspirin, ibuprofen or blood thinners in the last 24 hours? *

YES NO

Are you prone to heavy bleeding? *

YES NO

Have you consumed alcohol in the last 8 hours? *

YES NO

Do you have a latex allergy? *

YES NO

Are you pregnant or breastfeeding? *

YES NO

Are you prone to fainting? *

YES NO

Do you have any other allergies? *

write 'no' if no other allergies

Have you had the covid vaccination within the last 30 days? *

Yes No

Do you have any other conditions that might affect the healing? *

write 'no' if no other conditions

How did you hear about us?

A tattoo is made by depositing various colored pigments under the surface of the skin. The Q-Switched Nd: Yag and the Ruby Laser are the latest in a new class of state-of-the-art laser technology specifically designed for tattoo treatment. The following factors should be considered in your decision to undergo treatment with the Q-Switched Ruby or Q-Switched Nd: Yag Lasers.

· It may not be possible to remove 100% of your tattoo. Certain pigments are especially "stubborn" and may require multiple treatments.

· A series of treatments may be required averaging four to six sessions for amateur tattoos and eight or more sessions for professional tattoos.

· There may be a crust or scab on the skin requiring special care with topical antibiotic ointment, bandages and limitation of activity in some cases for a period of one to two weeks following treatment

· Indentation or depression of the skin may occur.

Each treatment, in rare circumstances you may experience the following side effects:

· Itching on or around area treated.

· Redness, swelling, bleeding or tingling or scarring, blisters or bruising (purpura)

· There is a risk of infection. Although infection following treatment is unusual, bacterial, fungal and viral infections could occur.

· There is a risk of bleeding. Pinpoint bleeding is rare but could occur following treatment. There may be a crust or on the skin requiring special care with topical antibiotic ointment, bandages and limitation of activity in some cases for a period of one to two weeks following treatment. Aftercare instructions will be provided at the end of your tattoo removal treatment.

· Skin Hyper-Pigmentation (brownish or dark discoloration) or Hypo-Pigmentation (lightening of the skin) may occur or scarring is a possibility post treatment.

· An allergic reaction to tattoo pigments with your immune system post laser treatment.

I acknowledge by signing this consent form that I have read and agree to the following:

· I have read the information sheet provided and fully understand its contents.

· I understand that exposure of my eyes to light could harm my vision, I must wear my eye protection goggles on at all times.

· I understand that the success of tattoo removal varies greatly depending on the age of the tattoo and the concentration of pigment colours.

· I understand that there is no guarantee that the laser will remove all the pigment. eg Yellows pigments and white pigments are not targeted.

· I understand that a shadow of the tattoo may be present after the treatments

· I am not under the influence of alcohol or drugs prescription or other and if so have discussed this with the Laser Operator

· I do not have any medical or skin conditions such as but not limited to: acne, scarring (Keloid), eczema, psoriasis, moles or sunburn in the area to be treated. If I have any type of infection or rash anywhere on my body, I will advise my Laser Operator.

· I willingly submit to these procedures with a full understanding of possible risks and side effects.

· I understand that my skin was originally scarred by the tattoo application needle. This injury may remain even if all the pigment is removed.

· I understand that my skin will be extremely sensitive to sunlight following the procedure, exposure should be avoided for 4 weeks following treatment and should refrain from tanning. Maximum SPF should be worn at all times.

· I understand that any employee or agent of Art On Skin when performing a laser tattoo removal does not act in the capacity of a medical professional. The suggestions made are just suggestions and they are not to be construed or substituted for advice from a medical professional.

· I release all rights to any photographs taken of me and the tattoo and give consent in advance to the reproduction in print or electronic form. I acknowledge that I had the opportunity to ask questions regarding this procedure and all questions were answered to my satisfaction

· I have read and understand this agreement and all my questions have been addressed and answered to my satisfaction. I consent to the terms of this agreement.

Signature *

Clear

Date *

Time of your appointment *

: Hour Minutes AM/PM Option

CONSENT FORM