Consent Form for Non-Invasive Magnetic Tattoo Removal for Microblading and Permanent MakeUp

Consent Form for Non-Invasive Magnetic Tattoo Removal for Microblading and Permanent MakeUp

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 NameMiddle NameLast Name
Date*

MonthDayYear
Date
Birth Date

MonthDayYear
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile Number*

Country CodeArea CodePhone Number
Please submit a picture of your ID/Passport:

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Health Declaration
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. We will assume no liability in the event you give false information to obtain the treatment.
Client Eligibility Criteria:

Age Requirement: The client must be 18 years or older to proceed with the treatment.

Identification: A government-issued ID must be presented to verify age and identity.

Pregnancy/Breastfeeding: Clients who are pregnant or breastfeeding cannot undergo the procedure due to potential risks to both the mother and baby.

Recent Treatments: Clients must not have had Botox or fillers on their face within the last 60 days, as this can affect the treatment results.

Medical Conditions: Any existing medical conditions must be disclosed to ensure the treatment is safe for the client.

Allergies: The client must inform the technician of any allergies to the products or materials used during the procedure.

Contraindications/Disqualification List:

Blood Conditions: Clients with transmittable blood diseases (e.g., HIV, HBV, HCV) are not eligible for the procedure.

Active Skin Cancer: Clients with active skin cancer in the treatment area cannot undergo the procedure.

Radiation/Chemotherapy: Clients currently receiving or planning to undergo radiation or chemotherapy are not eligible.

Skin Conditions: The presence of any skin diseases, rashes, or inflammation in the treatment area disqualifies the client.

Contagious Diseases: Clients with contagious conditions like Shingles or Chickenpox cannot have the procedure.

Post Inflammatory Hyperpigmentation (PIH): Clients with a history or current experience of PIH cannot undergo the procedure.

Skin Medications: Clients taking certain skin medications (e.g., Ro-Accutane, steroids) are not eligible.

Glaucoma/Diabetes/Hemophilia: Clients diagnosed with Glaucoma, Diabetes, or Hemophilia cannot have the procedure due to associated risks.

Heart Disorders: Clients with a history of heart disorders, heart attacks, or strokes are disqualified for safety reasons.

Epilepsy/Seizures: Clients with epilepsy, fainting spells, or seizures cannot undergo the procedure for safety concerns.

Healing Disorders: Clients with healing disorders that impair the body’s ability to recover are not eligible.

Cold Sores/Herpes (Lip Clients): Clients seeking lip procedures must not have active cold sores, fever blisters, or herpes outbreaks.
General Post-care Instructions:

1. Keep the Treated Area Clean and Open to Air: It is essential to maintain cleanliness and allow proper airflow to the treated area to facilitate healing and prevent infection. Avoid covering the area with bandages or occlusive dressings, as air/oxygen promotes faster healing.

2. Avoid Soaking the Treated Area in Water: To prevent disruption of the healing process, refrain from soaking the treated area in water. While showering is permitted, keep the area out of direct water spray and ensure it remains dry for optimal healing.

3. Restrict Certain Activities: Avoid activities such as bathing, swimming, saunas, hot tubs, tanning, or exercise during the initial healing period, as they can compromise the integrity of the treatment area and increase the risk of complications.

4. Do Not Disrupt the Scabbing Process: It is crucial to allow natural scabbing and healing of the treated area without interference. Picking, scratching, or disrupting the scabs can lead to delayed healing, scarring, and compromised aesthetic results.

5. Treat the Area with Care: Handle the treated area gently and avoid anything that could cause irritation or trauma. Refrain from touching the area with unclean hands and follow post-care instructions diligently to promote optimal healing.

6. Special Instructions for Lips: For lip procedures, use a straw for drinking, brush gently, and avoid biting into food to prevent unnecessary stress on the treated area. Additionally, refrain from certain activities that may strain the lips or compromise healing.

7. The use of red-light therapy is forbidden for one month after the session.
Preparation for Appointment (Magnetic Tattoo Removal):

1. Clean Face: Arrive at the appointment with a bare, clean face, free from makeup, toner, or moisturizer. This ensures optimal conditions for the procedure and enhances treatment efficacy.

2. Avoid Stimulants and Medications: Refrain from consuming alcohol, coffee, or other stimulants 24 hours before the appointment. Additionally, avoid specific medications that may increase bleeding or affect skin sensitivity.

3. Menstrual Cycle Consideration: Avoid booking appointments during the menstrual cycle, as hormonal fluctuations can impact pain sensitivity and treatment outcomes.

4. Avoid Eyebrow Treatments: Refrain from waxing, tanning, or tinting the eyebrow area for at least three days before the appointment to minimize skin irritation and ensure optimal treatment conditions.

5. Avoid Anti-aging Treatments: Avoid anti-aging treatments such as microdermabrasion,

retinol, chemical peels, laser, or facials for at least two weeks before the appointment to prevent skin sensitivity and potential complications.

Post-Care Instructions (Magnetic Tattoo Removal):

1. Gentle Care: Refrain from rubbing, picking, or scratching the treated area to avoid disrupting the healing process and promoting optimal results. Avoid makeup on the tattoo area for the specified duration to prevent infection and maintain skin integrity.

2. Sun Protection: Avoid sun exposure for at least one-week post-treatment to prevent skin damage and pigmentation changes. Use protective clothing and sunscreen to shield the treated area from harmful UV rays.

3. Activity Restrictions: Avoid certain activities such as swimming, sauna, hot baths, Jacuzzis, sun/salon tanning, and increased sweating for the specified duration to prevent complications and promote healing.

4. Seek Medical Attention: In case of fever, redness, swelling, or discharge at the procedure site, seek prompt medical care to address potential complications and ensure proper healing.

Aftercare Protocol (During and After Treatment):

1. No Numbing Used: Understand that no numbing is used during the treatment for better ink extraction, and tingling sensations may be experienced due to the alcohol content in the solution.

2. Immediate Aftercare: On the way home post-session, use a tissue to absorb lymph from the treated area. Expect itching and mild discomfort in the skin post-session, with the possibility of light scabbing.

3. Skin Recovery: Allow one to two weeks for the skin to recover, understanding that light pink coloration post-healing is normal and should not be considered scars. In summer, wear sunglasses or hats to protect the treated area from sun exposure.

4. Follow-up Sessions: Sessions can be performed every three to four weeks, as recommended by the technician, to achieve desired results. In case of recurrent herpes outbreaks, consult a doctor for prescription medication.

Specific Post-care Instructions for Eyebrows/Lips Tattoo Removal:

1. Aftercare Application: Apply the provided aftercare products multiple times daily as directed for optimal healing and maintenance of the treated area.

2. Interval Between Sessions: Allow a minimum of three weeks between sessions to facilitate adequate healing and prevent overexertion of the skin.

3. Daily Washing: Wash the face daily and reapply aftercare to the treated area to maintain cleanliness and support the healing process.

4. Smoking can impede the healing process and may increase the risk of complications.
5. It is recommended to refrain from smoking for at least two weeks after each treatment session.

Detox & Snow Lips Technique:

1. Aftercare Application: Apply the provided aftercare products frequently to promote healing and prevent infection. Avoid consuming stain-inducing substances and spicy foods to minimize irritation and discomfort.

2. Sun Protection: Avoid sun exposure and wear protective clothing or hats to shield the treated area from UV rays, reducing the risk of pigmentation changes and complications.

3. Hygienic Practices: Maintain hygienic practices and avoid smoking or drinking coffee immediately after treatment to support healing and prevent contamination of the treated area.

4. Follow-up Monitoring: Keep the technician informed of any concerns or changes in the healing process and seek medical attention if complications arise.

Avoid and Follow Instructions:

1. Post-Treatment Manners: Adhere to specific instructions post-treatment to optimize healing and prevent complications. Avoid activities and exposures that may compromise the treated area's integrity and follow guidelines diligently for best results.

2. Appointment Postponement: Understand the circumstances under which appointments should be postponed, such as recent Botox/filler injections, laser, or chemical treatments, and adhere to recommended timelines for optimal safety and efficacy.

Important Notes:

- Client Responsibility: The CLIENT acknowledges responsibility for adhering to all instructions and guidelines provided for pre-care, post-care, and appointment preparation.

- Technician Communication: Effective communication with the technician is essential for addressing concerns, monitoring healing progress, and ensuring optimal outcomes. The CLIENT should promptly notify the technician of any changes in health status or post-procedure complications.

- Informed Consent: By signing this consent form, the CLIENT acknowledges understanding and agreeing to all terms, conditions, and instructions outlined herein, demonstrating informed consent and commitment to treatment compliance.
By signing the field below, I acknowledge that I have read the Contraindications / Disqualification List, How to Prepare for Your Appointment, and Outcome of Procedure and understand that the result of the procedure may vary depending on numerous factors due to the nature and pathology of my skin.
Client's Signature

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Please submit a picture of your Tattoo*

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Which of the below Treatment do you want to undergo?

EyebrowsLip Liner/ Lip TattooEyelinerDetox Lips / Snow LipsMagnetic Detox Brows / Boost BrowsBody Tattoo RemovalScalp Micropigmentation RemovalIcy Lips
Have you done Botox or Filler in last 4 weeks? **

YesNo
Are you currently taking medication? If yes, please list the medication name and provide the date you last took the medication*

YesNo
In order to ensure the health and safety of our staff and clients, please answer the following questions truthfully and to the best of your knowledge. Your responses will be kept confidential.*

Heart conditionsDiabetesRefractive eye surgeryEpilepsy/seizuresHepatitis/jaundiceOcular herpesLips herpesStrokeGlaucomaShortness of breathHIVHyperpigmentationAccutane treatmentChest painTrichotillomaniaAutoimmune disorderKidney diseaseExcessive bleedingAlopeciaKeloid scarringCancerHemophiliaProlonged healing timesPregnant / BreastfeedingCurrently undergoing radiation/chemotherapyCurrently using retinol face productsMetal allergyTaking steroid medicationsHave previous cosmetic tattooingMicrobladingHave previous tattoo removal procedureLaser removalAcid / Saline removalTCA / PeelingAlkaline removalSensitivity / allergy to latexHistory skin with disease/sensitivityNone of TheseOther
Please list any medical conditions, issues, or medications not listed above:
I acknowledge that i have carried out one or more consecutive tattoo removal treatments with below treatment method. **

RejuviAcids: (Skinial - RCR - Enzymes -…)Saline (OCEAN + - Vanish -…)Home treatmentLaserIf other, Please name it,I have not done any treatment of Tattoo Removal before,
How many removal sessions done before?*
What is the condition of Skin having Tattoo?*

Skin is damaged and having scarsSkin has Scars due to other TreatmentsMy skin does not have any scars
I acknowledge having carried out one or more consecutive tattoo removal treatments and my skin may have invisible scars.
Tattoo Description and History*
If you are currently under a physician’s care for any condition, please describe:
Initials above
Do you have or have had any herpes infections or breakouts at the proposed procedure site?

YesNo
How often do you consume alcohol in a week?
Initials above
How often do you smoke a week?
Initials above
Do you have any allergies to cosmetic makeup? If yes, list the brand and type of reaction:
Initials above
Do you spend time in the sun? If yes, how often?
Initials above
Do you go swimming? If yes, how often?
Initials above
How often do you consume alcohol in a week?
Initials above
Have you had any laser treatments? If yes, please describe where and when?
Initials above
Have you had a chemical peel? If yes, please explain what type, how often and the last time you had a chemical peel:
Initials above
Have you had any facial cosmetic surgeries? If yes, please describe what type and when
Initials above
Do you plan to have lasik eye surgery? If yes, when
Initials above
Do you plan or have scheduled any Botox treatments? If yes, when?
Initials above
Are any colors in your tattoo(s) sensitive to the sun?

YesNo
By signing below I acknowledge by signing this release that I have been given the full opportunity to ask any and all questions which I might have about Magnetic Tattoo removal from the Technician that all of my questions have been answered to my full and total satisfaction.
Signature

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I specifically acknowledge that I have been advised of the matters set forth below and agree as follows:
I acknowledge that Magnetic Tattoo Removal is my choice alone. It will result in a permanent change to my appearance, and that needles and solution will work on my skin. No representations have been made to me as the ability to later restore the skin involved to the original condition
Initials above
I am not pregnant or nursing. I do not have any history of herpes infection at this proposed procedure site. I do not have epilepsy, diabetes, allergic reaction to latex or antibiotics, hemophilia or other bleeding disorder. I do not have cardiac valve disease or suffer from any heart conditions or take medications that thins my blood.
Initials above
I acknowledge and give consent to this Technician to use images of my tattoo(s) for marketing and, or publishing purposes in various media such as the internet, magazine, printed and or television etc
Initial above
I understand I will have Magnetic Tattoo Removal performed using appropriate instruments and sterilization techniques. I understand that the saline tattoo removal site usually takes 2 weeks or longer to heal. I agree to release and forever discharge, and hold harmless, the Technician, all employees, contractors and the management of the permanent make-up studio from any and all claims of negligence, damages, or legal actions arising from or connected in any way with my tattoo, the procedure and conduct used in my saline tattoo removal and assume all responsibility for the decision(s) made consenting to this permanent procedure.
Initial above
I do not have a history of medication use or currently using medication, including being prescribed antibiotics prior to dental or surgical procedures.
Initial above
I accept FULL RESPONSIBILITY for any complications that may arise during or after the procedure and service provided, which is being performed at my request and approval.
Initial above
If you experience any signs or symptoms of an oncoming infection including, but not limited to: redness swelling tenderness of the procedure site, red streaks going from the procedure site toward the heart, elevated body temperature, or purulent drainage from the procedure site, YOU MUST SEEK MEDICAL CARE FROM A FAMILY PHYSICIAN OR MEDICAL PROVIDER AND NOTIFY THE ARTIST IMMEDIATELY
Initial above
I acknowledge that I have received a copy of aftercare instructions after initial procedure and was verbally instructed by the technician.
Initial above
I understand there will be no refunds if the desired Removal result is not achieved.
Initial above
For skin types V and VI; I understand that I am at a higher risk for hyper-pigmentation and hypo-pigmentation than other skin types. I agree to the risk involved.
Initial above
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
Initial above
Cancellation Policy:

We understand that circumstances may require cancellations. To accommodate this, we ask for a 72-hour notice if you need to cancel. Please note that failing to cancel or attend an appointment results in costs incurred by us. If a 72-hour notice is not provided 100% session fee will be charged.
I have read and understand the cancellation policy of the service provider and agree to abide by the above conditions.

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Service Agreement
1. Services to be Provided: The office provides permanent makeup/cosmetic tattoo services and tattoo removal services
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2. Payment: A non refundable booking fee is required to secure your appointment prior to the service. The booking fee is applied to the service grand total and the remaining balance is to be paid at the end of the service performed.
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3. Client Cooperation: This Agreement contemplates full Client cooperation in the course of services agreed upon. Our office policy requires 72-hour advance notice for appointment cancellation. Failure to do so may result in additional service charges to be added during next appointment
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4. Termination: Subject to the provisions of paragraphs 5 and 6 of this Agreement, the Client may discontinue care and terminate this Agreement at any time by written notice to that effect delivered in person, or by mail, to the office. Such “notice of termination” shall discharge the office from all further obligations and/or duty to render care to the client. The office reserves the right to terminate this Agreement in its sole discretion notwithstanding any other terms or provisions of this Agreement
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5. No Refunds: To encourage commitment and follow-through, the service provider offers no refunds. No refunds will be made on any services or treatments. There will be no exceptions.
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6. Release of Liability: Client agrees to indemnify, hold harmless and release the service provider, its agents, employees, officers, directors, representatives, assigns, members, affiliated organizations, and insurers, and others acting on the Company's behalf, of all claims, demands, causes of action, and legal liability, whether the same be known or unknown, anticipated or unanticipated, and further agrees that except in the events of the Company's gross negligence or willful and wanton misconduct, no claims, demands, legal actions and causes of action, shall be made against the Company for any economic and non-economic losses of any kind.
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7. Complete Agreement: This Agreement constitutes the complete agreement and understanding between Client and Office and will not be changed or modified in any way unless agreed to by both parties in writing
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8. Reschedule/Cancelations: We require 72-hour advance notice to reschedule or cancel an appointment. One reschedule is allowed free of charge. All future rescheduled appointments require a brand new booking fee. Pre-payment in full is required to reschedule after 3 reschedules or more
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THE CLIENT HAS FULLY READ THIS AGREEMENT AND ANY SUPPLEMENT HERETO, AND UNDERSTANDS AND AGREES TO ABIDE BY ALL OF THE TERMS HEREOF.

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Consent Form for Non-Invasive Magnetic Tattoo Removal for Microblading and Permanent MakeUp

Service Agreement