Laser Consent

The Vault Laser Company

Please read and respond.
How did you hear about us?*
If other, please list.*
Have you used drugs or alcohol in the last 12 hours?*
Are you currently pregnant or breastfeeding?*
Are you currently under the care of a doctor or dermatologist? If yes, for what reason?*
Please explain:
Do you suffer from diseases affecting the immune system such as diabetes or rheumatoid arthritis?*
Do you suffer from photosensitive epilepsy?*
Have you used "Accutane" treatment in the last 6 months?*
Do you have any health problems or are you taking medications that create photosensitivity or cause healing problems? If yes, please explain.*
Please explain:
I agree to release The Vault Laser Company and Ryan Peña and its representatives from any liability relating to the consequences, of whatever nature, present or future, which may arise following the requested intervention. I acknowledge having voluntarily used the services of The Vault Laser Company in order to undergo the requested intervention and accept all risks and consequences that may arise following it. *
I understand that the tattoo removal process will take several treatments and that some tattoos will be impossible to completely remove. I understand that this process may leave permanent marks on my skin or create changes in melanin and hair in the treatment area.*
I agree that photographs taken of my tattoo may be published for commercial or portfolio purposed by The Vault Laser Company and its representatives. *
If any section or provision of this release is found to be unenforceable or invalid, that part will be severed from this agreement. The remainder of this agreement will then be construed as if the unenforceable portion had never been contained herein.
I hereby declare that I am of the minimum age required and that I am in full possession of all my skills to validate this form.
Name*

First NameLast Name
Phone Number*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of birth*

MonthDayYear
Date
Email*
example@example.com
Please type your full name to serve as your signature. *
Cancelof
Artist*
Date

MonthDayYear
Date
Hour Minutes
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The Vault Laser Company

If any section or provision of this release is found to be unenforceable or invalid, that part will be severed from this agreement. The remainder of this agreement will then be construed as if the unenforceable portion had never been contained herein.