LSM Tattoo Removal

Client’s Name *

First Name Last Name

Client’s Date of Birth

Date

Client’s Phone Number *

Client’s E-mail *

example@example.com

Client’s Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Today’s Date (or Date of Appointment)

Date

Describe the tattoo to be lightened:

Area on the body tattoo is located:

Which of the following describes your skin type?

Always burns, never tans Always burns, sometimes tans Sometimes burns, always tans Rarely burns, always tans Brown skin tone, moderately pigmented skin Black skin tone

Any medical conditions?

Yes No

If yes, please list and describe here:

Any medications/prescriptions?

Yes No

If yes, please list and describe here:

Before your appointment, please be sure to avoid blood thinners, alcohol, ibuprofen, and any other pain relievers 24-48 hours before your appointment. Caffeine the day of the procedure may increase discomfort levels and blood flow. It is also advised to avoid heavy exercise 24 hours prior and 10-14 days following your procedure. Those on their menstrual cycle will experience greater sensitivity. No tanning for 72 hours before your appointment. Finally, get ahead on your dirty work – no dusting, lawn mowing, changing the cat litter or any chores that will get dirt/bacteria on the healing area.

Contraindications - You are not a candidate for micropigmentation if any of the following apply to you:

Currently diagnosed with COVID-19 virus
Pregnant or breastfeeding
Sever Lupus
Abnormal heart conditions
Hepatitis B/C
HIV/AIDS
Diagnosed with immune disorders and/or taking immunosuppression medication
Currently undergoing chemotherapy
Active Vitiligo*
Severe Rosacea
Blood Disorders: Sickle Cell, Hemophilia
Keloid extremely easily
Chronic anxiety
Those who have had eye surgery in the last 6 months or Lasik/Cataract 1 month prior, 3 months post op
Diagnosed with trichotillomania
Accutane (must be off for 12 months)
Steroids (must be off for 6 months)
Those who have had laser resurfacing in the past year
Active skin disorders: cold sores, Shingles, Impetigo, Psoriasis, pink eye, sun burn, severe acne, rashes

Restrictions – You may or may not require a visit to and clearance from your doctor if some of the following restrictions apply to you:

Previously diagnosed with COVID-19 virus or had any contact with people diagnosed with it
Diabetes (specifically Type 1)
Narcolepsy
Taking blood thinning medication
Retinol/Retin-A must be discontinued 1 month by or around the area of
micropigmentation prior to procedure. (It will cause the skin to bleed).
Injections (Botox, JuvaDerm, Voluma, etc.) must be done 3 weeks before or after procedure.
Chemical peels, laser treatments and microneedling may not be done within 60 days before or after procedure.
The use of lash growth serums (such as Latisse®, Babe Lash®, etc.) must be discontinued at least 3 months prior to your eyeliner procedure (it creates an inflammatory response, causes excess bleeding and prohibits the eyeliner from healing well).
The use of lip plumpers (such as Too Faced® Lip Injections, Grande Lips®, etc.).
The use of brow growth serum (such as Grande Brow®) must be discontinued for at least 2 months.
Sunburned or suntanned skin is damaged skin and therefore will cause excessive bleeding. (I CANNOT work on sunburned or regularly suntanned skin.)
You cannot expose the area to the sun for 30 days before or after procedure.
Avoid ALL alcohol and caffeine products 24 hours before procedure to minimize any oozing, bleeding or swelling.
Do not take aspirin or ibuprofen 3 days prior to procedure unless medically necessary.

Please answer specified questions pertaining to the COVID-19 virus pandemic:

Have you been diagnosed with COVID-19? If so, when? (Please explain below) If you were diagnosed, have you been cleared? If so, when? (Please explain below) Have you had close contact with anyone diagnosed with COVID-19 in the last 30 days? If so, when and how many times? (Please explain below) Are you currently feeling any COVID-19 symptoms or flu-like symptoms in general? Symptoms can include but are not limited to fever, cough, shortness or breath, chills, sore throat, new loss of taste or smell, muscle or body aches, nausea or vomiting and diarrhea. Have you recently traveled far via automobile or aircraft in the last 30 days? If so, when? Where? And how long? (Please explain below) Have you received the COVID-19 vaccine? If so, when? (Please date below)

If yes, please describe here:

The nature and method of the proposed pigment (tattoo) lightening procedure has been explained to me including risks 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/cold sores 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 process.

I understand there are medical options available for pigment (tattoo) removal I have decided to decline those methods and proceed with this procedure.

I understand that the unwanted pigment may not be successfully lightened to the point that it can no longer be seen. Scarring, hyperpigmentation or hypopigmentation, 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 technician, the studio (location and its owner) 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.

*For skin types V and VI: I understand that I am at a higher risk for hyperpigmentation and hypopigmentation than other skin types. I agree to the risk involved.

I understand that lightening tattoo pigment is difficult, if even possible. As a result, I will not hold my technician or the 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, marketing and/or teaching purposes.

I agree to follow all aftercare instructions provided by me by my technician.

I have been duty informed of the natures, risks, possible complications and consequences as listed above. I further understand that my technician is not a medical doctor.

There is a fee for this service and additional fees for all additional sessions. The fee's have been explained to me and I agree to the fees. Fees for the additional session(s) cannot be determined until the results from this first session are complete and how much needs to be done the additional session(s) can be determined.

I have disclosed all that has been asked of me to the best of my ability and I understand all information listed above. I have had all my questions answered, and agree to all conditions and provisions of this document as evidenced by signature below. I accept the risks for having this procedure done, therefore, I release my technician and the studio from any and all liability.

COVID-19:

I understand that I am opting for a service that is not urgent and not medically necessary.
I also understand that the coronavirus disease (COVID-19) has been declared a worldwide pandemic by the World Health Organization. I further understand COVID-19 is extremely contagious. State and federal health agencies recommend social distancing. I recognize that the staff at Lorena Soto Makeup LLC are closely monitoring this situation and have put in place reasonable preventive measures targeted to reduce the spread of this virus. However, given the nature of the virus, I understand there is an inherent risk of becoming infected with COVID-19 if I proceed with this elective service.

Accordingly I acknowledge and assume the risk of becoming infected with COVID-19, and any variation or mutation thereof, through this elective service and I gave my express permission to proceed with the same. This consent applies to any follow up or additional services in the upcoming months. I understand that even if I have been tested for COVID-19 and received a negative test result, the tests may not have detected the virus or I may have contracted COVID-19 after the test. I will not hold this business and professional offering the service responsible for any liability related to COVID-19 and any variation or mutation thereof.

I understand that exposure to COVID-19 before, during, or after my procedure(s) may result in complications and/or delayed healing. I have been given the option to defer my service to a later date. However, I understand all the risks including those noted herein and I would like to proceed with this service. I understand the explanation and consent to the procedure.

Furthermore, I have been informed of the nature, risks, and possible complications and on sequences of permanent skin pigmentation. I understand the permanent skin pigmentation procedure carries with it known and unknown complications and consequences associated with this type of cosmetic procedure, including but not limited to: infection, allergic reaction, scarring, inconsistent color, pigment migration, fanning or fading of pigments. I understand that all pigments and inks are not FDA-approved and that the actual color of the pigment may be modified slightly, due to the tone and color of my skin. I fully understand that this is a tattoo process and therefore not an exact science, but an art. I request the permanent skin pigmentation procedure(s), and fully accept the possible permanence of the procedure as well as any possible complications and consequences of the said procedure(s).

I understand that COVID-19 may cause additional risks, some or many of which may not currently be known at this time, in addition to the risks described herein, as well as those risks for the service itself. I have been given the option to defer my service to a later date. However, I understand all the potential risks, including but not limited to the potential short-term or long-term complications related to COVID-19, and I would like to proceed with my desired services.

Signature

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Permanent Makeup Tattoo Removal