PERMANENT MAKEUP REMOVAL CONSENT FORM

NAME

First NameLast Name

TODAYS DATE

Date

DATE OF BIRTH

Date

PHONE NUMBER

Please enter a valid phone number.Format: (000) 000-0000.

DESCRIBE THE TATTOO THAT NEEDS TO BE LIGHTENED:

LOCATION ON THE BODY WHERE THE TATTOO THAT NEEDS TO BE REMOVED IS:

ARE YOU ON ANY MEDICATIONS OR DO YOU HAVE ANY MEDICAL CONDITIONS?

If yes to the question above, please list here:

ARE YOU ALLERGIC OR HAVE HAD A REACTION TO ANY TYPE OF SALT AT ANY TIME?

ARE YOU ALLERGIC TO CITRUS (ORANGE OR LEMON)?

ARE YOU ALLERGIC TO ALOE VERA?

WHICH OF THE FOLLOWING BEST DESCRIBES YOUR SKIN TYPE?

PLEASE READ AND CHECK ALL THAT APPLY

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 the procedure. 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 may occur on the lips following lip procedures in individuals prone to this issue. Secondary infection in the area of the procedure may occur, however if properly cared for, this is rare.

SIGNATURE

PERMANENT MAKEUP SALINE REMOVAL CONSENT FORM