Consent for Pigment Lightening
Name
First Name
Last Name
Date
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
DOB
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone/text message #
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Area to be Lightened/Removed
Are you on any medications or do you have any medical conditions?
Yes
No
If YES, please inform here
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 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 problem. Secondary infection in the area of the procedure may occur, however if properly cared for, this is rare. (Client Initials)
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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. (Client Initials)
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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, discoloration 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, Ink'd Cosmetics, 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. (Client Initials)
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I understand there will be no refunds if the desired lightening result is not achieved. (Client Initials)
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Which of the following best describes your skin type? (Please select one number)
I. Always burns, never tans
II. Always burns, sometimes tans
III. Sometimes burns, always tans
IV. Rarely burns, always tans
V. Brown, moderately pigmented skin
VI. Black skin
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. (Client Initials)
*
I understand that lightening tattoo pigment is difficult, if even possible. As a result I will not hold my technician or Ink'd Cosmetics responsible for any resultant failure to lighten the unwanted pigment. (Client Initials)
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I agree to submit to before and after photographs, and give my permission to use such photographs for publication and/or teaching purposes. (Client Initials)
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I agree to follow all aftercare instructions provided by me by my technician. (Client Initials)
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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. (Client Initials)
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There is a fee for this service and additional fees for all additional sessions. The fee's have been explained to me and I agree to the fees. The fee for this first session is
Fee's for the additional session(s) cannot be determined until the results from this first session are complete and how much needs to be done the additional session(s) can be determined. (Client Initials)
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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 signature below. I accept the risks for having this procedure done therefore release my technician and the Ink’d Cosmetics from any and all liability. (Client Initials)
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Signature of Client (Signature applies to consent to process during agreed treatment plan period)
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Witnessed by Technician Performing Removal/Lightening Procedure.
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
TECHNICIAN NOTE PAGE
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Client Name
First Name
Last Name
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