Saline Tattoo Removal Consent Form
Please be advised that I am obligated to perform procedures in strict compliance with all hygiene and health protection measures. This information is confidential and it shall also be handled in that way.
Name
*
First Name
Last Name
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Date of Birth
*
-
Year
-
Month
Day
Date
Upload a clear photo of the area in question
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Cancel
of
How many sessions of permanent makeup have you had on the area?
1
2
3
4
5
5+
What are your desired results?
Lightening
Full removal
Eventually fresh work on the area
Have you have any previous removals on the area?
Yes
No
Health Questionnaire
Please understand that this treatment is not for everyone. In order to find out if you are fit for this procedure, please answer the following health questions truthfully. Pink Fluff Tattoo will assume no liability in the event you give false information to obtain the treatment.
Check the box if the following apply to you:
Please list any medical conditions, issues, or medications not listed above:
Terms & Conditions
*
Today’s Date
-
Month
-
Day
Year
Date
Signature
*
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Submit
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