Tattoo Removal Medical and Consent Form
Name
*
Date
*
/
Month
/
Day
Year
Date
Age
*
Address
*
Address
Street Address Line 2
City
State
Zip
Phone
*
How did you select me for your procedure services?
Are you pregnant or nursing?
Yes
No
Have you had any alcohol in the past 24 hours?
Yes
No
Have you ever had cold sores or fever blisters?
Yes
No
Do you have any allergies to latex?
Yes
No
Have you had any laser or chemical peels in the area within the last 6 months?
Yes
No
Do you bruise easily?
Yes
No
Do you routinely use Retin-A, glycolic, or other exfoliating products?
Yes
No
Are you allergic or sensitive to any metals, for example, metals used for jewelry?
Yes
No
Do you have problems healing?
Yes
No
Do you have oily skin?
Yes
No
Do you use tobacco? If you use tobacco you may heal slower and this affects the timing on scheduling a touchup appointment, if applicable.
Yes
No
Do you have any heart conditions?
Yes
No
Are you diabetic?
Yes
No
Do you have any autoimmune disorders or thyroid disorders?
Yes
No
Do you have Botox or Fillers in the area being treated?
Yes
No
Do you have hyperpigmentation or hypopigmentation?
Yes
No
Do you tend to keloid or form hypertrophic scarring?
Yes
No
Do you tend to faint easily or get dizzy?
Yes
No
Do you bleed excessively from minor cuts?
Yes
No
Are you currently on any medications or treatments, if so, please list them.
Please initial each of the following sections.
The nature and method of the proposed pigment (tattoo) lightening procedure has been explained to me including risks and/or possibility of complications during or following its performance. I understand there may be a certain amount of discomfort or pain associated with the procedure and that the other adverse side effects may include: minor and temporary bleeding, bruising, redness or other discoloration and swelling. Fever blisters may occur on the lips following lip procedures in individuals prone to this problem. Secondary infection in the area of the procedure may occur, however if properly cared for, this is rare.
*
I understand that several treatments may be needed in order to attempt to achieve my desired results. However, I have not received any guarantees to the quality of the outcome of the process
*
I understand that the unwanted pigment may not be successfully lightened to the point that it can no longer be seen. Scarring as hyper-pigmentation or hypo-pigmentation, discoloration or other damage to the skin may occur during this process and may be permanent. This is rare but it can happen. I will not hold my technician and/or the distributor/manufacturer of tattoo removal products used in this attempted pigment (tattoo) lightening or removal liable for any damages that may occur to my person.
*
I understand there will be no refunds if the desired lightening result is not achieved.
*
I understand that lightening tattoo pigment is difficult, if even possible. As a result I will not hold my technician and/or Studio responsible for any resultant failure to lighten the unwanted pigment
*
I agree to submit to before and after photographs, and give my permission to use such photographs for publication and/or teaching purposes.
*
I agree to follow all aftercare instructions provided by me by my technician.
*
I have been duly informed of the natures, risks, possible complications and consequences as listed above. I further understand that my technician is not a medical doctor.
*
I have been duly informed of the natures, risks, possible complications and consequences as listed above. I further understand that my technician is not a medical doctor.
*
Client Signature
*
Front of ID
*
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Back of ID
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Area being treated
*
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