Laser Tattoo & Pigment Removal Consent Form

Laser Tattoo/Pigment Removal CONSENT FORM

Please ensure you have completed the Consent Form at least 48 hours prior to your treatment appointment. Failure to do so may result in your appointment being postponed and the loss of your deposit. If you have any concerns in the meantime please contact us on 07765245406 or info@justbrowsinc.com
Personal Information
Name*

First NameLast Name
Date of Birth*

DayMonthYear
Date
Address*

Street Address

Street Address Line 2

CityCounty

Post Code
E mail*
example@example.com
How did you hear about us?
What areas (e.g. legs, face, brows) are you interested in having laser tattoo removal?*
Have you used any of the following in the past 30 days?*

Tanning in the sunSelf-tanning creamSun bedsNONE APPLY
When was your last sun holiday, and when is your next sun holiday?*
Gender*

MaleFemalePrefer Not To Say
Medical Information
Do any of the following apply to you? Please tick those that apply:*

Heart DiseaseBurns or skin graftsPolycystic Ovarian SyndromeHirsutismLiver or Kidney DiseasePort Wine stainHaemangiomaShinglesSteroid or Hormonal therapyThyroid Hormonal deficiencyDiabetesAids/HIVGold InjectionsHaemophiliaAnti-coagulantsAcneCancer (or radiation/chemotherapy)Herpes (or cold sores)Keloid formation/scarsMelanoma/molesEpilepsyPsoriasisSkin PigmentationVitiligoHormonal imbalancesLupus DiseaseClotting disordersAnti-inflammatory medicationPregnantBreastfeedingNONE APPLY
Specify any medical condition that is not listed above:
What area(s) (e.g. legs, face, brows) are you interested in having tattoo removal:*
List any current medication(s) that you are taking:
Have you ever used or currently using Retin A or Glycolic Acid?*

YesNo
Have you ever used or are you currently using Roaccutane?*

YesNo
What products are you currently using in your skin (including body products)?
If you have any implants, list the area:
Do you have any skin sensitivities or allergies?*

NoYes
If yes, please specify:
Have you had any major surgery performed in the last 3 months?*

NoYes
If yes, please specify:
Informed Consent
I hereby authorise Just Brows Inc. Ltd to treat me using the AW3® system.

I understand that the reduction/ removal may not be 100%. I also understand that the treatment using the AW3® system may need to be performed in repeated sessions in the future to obtain optimal results.

I have been informed about alternative treatment possibilities and I understand that other forms of treatment or no treatment at all, are choices that I have.

I understand that there are certain risks associated with the treatment and they include but are not limited to the following:

- Post-treatment discomfort like localised swelling, redness and mild tenderness.

- Although uncommon the treatment may cause blisters or light burns to the surface of the skin. (Light /Laser Treatment Only)

- Transient hypo or hyper pigmentation may occur and will normally fade in 3 to 6 months.

- Crust formation "dirty skin" look is commonly seen for up to 10 days after treatment. (Light /Laser Treatment Only)

- Scabbing, Swelling, and bleeding can occur but these are temporary. (Light/Laser Treatment Only)
Client Understanding
Do any of the following apply to you? Please tick those that apply:*

Heart DiseaseBurns or skin graftsPolycystic Ovarian SyndromeHirsutismLiver or Kidney diseasePort Wine stainHaemangiomaShinglesSteroids or hormonal therapyThyroid hormone deficiencyDiabetesAids/HIVGold injectionsHaemophiliaAnti-coagulantsAcneCancer (or radiation/chemotherapy)Herpes (or cold sores)Keloid formations/scarsMelanoma/MolesEpilepsyPsoriasisSkin PigmentationVitiligoHormonal ImbalancesLupus DiseaseClotting DisordersAnti-inflammatory medicationPregnantBreastfeedingNONE APPLY
Below are a list of treatment(s) that will apply to me when accepting this consent.

Laser Tattoo Removal/ Pigmentation/ Thread Vein/ Rejuvenation/ Birthmark Removal

Laser treatment is a method of removing tattoos. The purpose of the treatment is to achieve improvements in the appearance of the skin by removing the unwanted tattoo/pigment within the dermis of the skin using the AW3R Laser system.

Accepting Terms and Consent*

I agree to follow the post treatment recommendations advised by operator/company above in order to ensure the best possible results. For Light/Laser Treatments, I understand that excessive heat should be avoided for 48 hours and that exposure to the sun, including sun beds, must be avoided for 30 days before treatment and 30 days after treatment. A sun block of SPF 30+ must be used on the exposed skin areas, otherwise it might be possible that blotchy skin pigmentation, hyper- or hypo-pigmentation might occur.

I agree to co-operate with the recommendations of the company or the personnel while I am under their care, realising that any lack of co-operation could result in less than optimum results.

I agree to inform the above operator/company immediately if any adverse effects occur.

I agree to photographic documentation of the treated area both before and after the treatment.

I certify that I have read the entire informed consent and I agree to all its provisions. I certify that I have had the opportunity to ask questions and these questions have been answered to my satisfaction. I fully understand the treatment conditions and procedure.

I agree to pay for the above mentioned services (unless expressly stated in your booking information) and understand that there will be no refunds for any performed services. This consent form and cost covers above selected treatments only. Additional treatments can be added to this consent form and will be charged for as per clinic price list, including single shot treatments.

I have been made aware of the risks and I accept these terms and conditions as part of my treatment. We accept no liability for any of the above side effects. By accepting this, I agree to the terms and conditions and in the event of any of the above. I or any of my representative will not pursue the above person / company in any means of compensation.
Photography & Video Release Consent

Our insurance company requires 'before' and 'after' photos/videos to be taken and kept on file. We would like your permission to use these photos/videos for advertising purposes. Your consent is necessary regarding this. Please note this consent is always implied with 'Pay With Smile' and all modelling appointments.
Please select option below to indicate your preference to the above statement*

YesNo
Name*

First NameLast Name
Signature*

Clear
Date*

DayMonthYear
Date
Should be Empty:

Laser Tattoo/Pigment Removal CONSENT FORM

Personal Information

Medical Information

Informed Consent

Client Understanding

Photography & Video Release Consent