Pigment Lightening & Removal Consent Form
Please ensure that you have completed the Consent Form at least 48 hours prior to your treatment appointment, unless booking emergency removal.Failure to do so may result in your appointment being postponed.If you have any concerns in the meantime please contact us on 07765245406 or info@justbrowsinc.com
Name
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Name
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First Name
Last Name
Email
*
example@example.com
Date of Birth
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/
Day
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Month
Year
Date
Address
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Address
*
Street Address
Street Address Line 2
City
County
Post Code
Phone Number
-
Area Code
Phone Number
Mobile Number
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Describe the type of tattoo to be lightened:
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Describe the area on the body where the tattoo is located:
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Are you on any medications or do you have any medical conditions? Please list below:
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Allergens
Below are the names of the specific allergens used in the lightening solution. If you have any allergies to any type of salt, Aloe Vera or citrus (specifically orange or lemon) please ensure you tick the relevant box.
Do you suffer from allergies to any of the following ingredients?
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1. Aloe Barbadensis Leaf Juice (Aloe Vera)
2. Citrus Aurantium Dulcis Extract
3. Citrus Medica Limonum
4. Calendula Officinalis
5. Hydroxyethyl Cellulose
6. Sodium Benzoate
7. Potassium Sorbate
8. NONE APPLY
Client Consent
Please read through and check boxes next to the following statements to confirm your understanding.
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 maybe 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.
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Agree
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.
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Agree
I understand there are medical options available for pigment (tattoo) removal. I have decided to decline those methods.
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Agree
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, discolouration 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, Just Brows Inc. Ltd 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.
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Agree
I understand that there will be no refunds if the desired lightening is not achieved.
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Agree
Skin Type
Which of the following best describes your skin type?
Tick one that applies.
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Type 1. Always burns, never tans
Type 2. Always burns, sometimes tans
Type 3. Sometimes burns, always tans
Type 4. Rarely burns, always tans
Type 5. Brown, moderately pigmented skin
Type 6. Black skin
For Fitzpatrick skin types 5 and 6; I understand that I am at a higher risk of HYPER-pigmentation and HYPO-pigmentation than other skin types. I agree to the risk involved.
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Agree
I understand that lightening tattoo pigment is difficult, if even possible. As a result I will not hold my technician responsible for any resultant failure to lighten the unwanted pigment.
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Agree
I agree to submit to before and after photographs, and give my permission to use such photographs for publication.
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Agree
I agree to follow all aftercare instructions provided to me by my technician.
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Agree
I have been duly informed of the natures, risks, possible complications and consequences as listed above.
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Agree
I understand that my technician is not a medical doctor.
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Agree
There is a fee for this service and additional fees for all additional sessions, unless otherwise stated in writing upon booking.*
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Agree
Fees for the additional session(s) cannot be determined in advance as it is not possible to determine exactly how many sessions may be required to reach the desired outcome.
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Agree
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 my signature check box below. I accept the risks for having this procedure done and therefore release my technician and/or Just Brows Inc. Ltd from any and all liability.
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Agree
I understand that my temperature will the taken on arrival and that I may be refused entry if the result is above 37.7 degrees.
*
Agree
Signature
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Date of Signature
*
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Day
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Month
Year
Date
I prefer to be contacted by:
Email
Phone
Text
Submit
Should be Empty: