Botched Ink®Saline Tattoo RemovalClient Record, Consent & Medical Health Form
Name
First Name
Last Name
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of birth
-
Month
-
Day
Year
Date
Treatment Plan
Filled in by the practitioner
Aftercare supplied
Treatment area
Price first treatment
Price future visits
Length of time between bookings
Lighten / Improve / Remove
Existing Tattoo
Type of tattoo and pigments used
Who carried out the tattoo
How old is the tattoo
How many top ups
Client ever liked tattoo
Tried other removal methods
Result of other methods
What is disliked now
Medical Health Form
Please answer YES or No to the following
Type a question
YES
NO
Are you over 18 years of age ?
Are you pregnant or nursing ?
Are you under the influence of alcohol or illegal drugs ?
Do you feel fit, well and able to have the treatment today ?
Do you have allergies to any medicine or products (aloe vera) ?
Was your tattoo difficult to heal or problematic at any time ?
Are you taking any medication, supplements, strict / unusual diet
Do you suffer from cold sores, fever blisters in the area to be treated ?
Do you have or are you having any fillers, injectables or chemical peels ?
Are you currently tanned or is your skin lighter than normal
Do you have any holiday plans within the next month ?
Do you have epilepsy, diabetes, high or low blood pressure ?
Do you knowingly have Hepatitis or any other infectious diseases ?
Do you take any blood thinners or anti inflammatories ?
Are you aware that you bleed easily ?
Are you 5 weeks post chemotherapy treatment ?
Do you have any respiratory problems?
Do you have fainting attacks ?
Do you have any problems with wounds healing ?
Do you suffer from hypertrophic or keloid scarring ?
Do you have hyperpigmentation (dark) or hypopigmentation
(light) anywhere on your body ?
Do you have any diagnosed or undiagnosed skin conditions ?
Notes
Signature
Terms of your treatment
Please answer Yes if you agree or No if you disagree with these terms
Type a question
Yes
No
I understand tattoo removal is a process with many variables, therefore how much pigment is removed during each visit, or how many visits are needed,cannot be known or guaranteed
I understand that a patch test can determine within 24 hours if I may have a reaction to Botched Ink® solution, but that it is inconclusive regarding whether I will have an allergic reaction at any time in the future, to the\release of tattoo pigment from the skin, or to the product. Therefore, I waiver my option to a patch test and wish to proceed with the treatment
I understand that additional work cannot be undertaken for 8 weeks to allow the skin to fully heal
My technician has discussed likely outcomes with me, recommending a treatment plan, prior to any work being agreed and carried out
I agree that my technician will use this client file and treatment plan to record my details, and a log of treatments and techniques used.
I understand I can request to see this file at any time
I understand that after each treatment the treated area may swell, show redness, and, in some cases, bruising. My technician will recommend how to take care of this
I have been given aftercare instructions and I understand that I must adhere strictly to these instructions.
I understand my technician can not give medical advice in the unlikely event of an infection, so I will immediately seek attention from a GP, Doctor or pharmacist
I understand any health condition or medication may affect the treatment including bruising, bleeding, healing and how much pigment removes
I understand the importance of providing an accurate and complete medical history and that withholding any medical conditions may be detrimental to my health and the outcome of the procedure
I understand that there are no guarantees as to the success of my Botched Ink® saline tattoo removal treatment, I also understand no refunds can be given as a treatment has been carried out
Signature
Photographic & Video Release Form
I give my verbal and written consent for any photographs or video footage taken to be used by mytechnician and their company for promotional purposes i.e social media, website, advertising.
Signature
Informed Consent
My technician and I confirm we have discussed, read through and completed this paperwork for thetreatment I am about to have. I give my informed consent to having this and future Botched Ink®Saline Tattoo Removal treatments
Signature
Date
-
Month
-
Day
Year
Date
Signature technician
After Treatment
My treatment has been carried out to my satisfaction and I have been given the opportunity to discuss any immediate concerns with my technician. I fully understand my aftercare instructions.
Botched Ink® aftercare sheet
Prescribed aftercare
Next appointment
Tolerance / Bleeding
Photos / Video
Notes
Signature
Date
-
Month
-
Day
Year
Date
Further Treatments
Type a question
Describe Healing& Aftercare
Any Medical Changes
Treating SameArea
Needles Used
Client to sign & date
2nd
3rd
4th
5th
6th
Submit
Should be Empty: