Medical History Form for Laser Tattoo Removal

Medical History Form for Laser Tattoo Removal
In order to provide you with the most appropriate laser tattoo removal plan, we need you to complete the following questionnaire. A current medical history is essential for the caregiver to provide appropriate procedures. All information is strictly confidential. Please note the minimum age for tattoo removal is 18.
Name

First NameLast Name
Date

DayMonthYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address
example@example.com
Date of Birth

DayMonthYear
Date
Gender
Occupation
Family Doctor
Phone
Emergency Contact Name
How did you hear about us?
Have you had laser tattoo removal before?

YesNo
If yes, who did the treatment?
Skin Type:

The Fitzpatrick Scale is a numerical classification for human skin colour developed in 1975 by Harvard dermatologist, Thomas B. Fitzpatrick. It classifies the typical response of different types of skin to ultraviolet (UV) light and remains a recognized tool for research into skin colour.

This section requires you to choose only one of the skin types based on the Fitzpatrick scale.

Please select the option that most applies to you in each section
Eye Colour

0. Light colours1. Blue, grey or green2. Dark3. Brown4. Black
Natural hair colour

0. Sandy red1. Blond2. Chestnut3. Dark Brown4. Black
Skin Colour (unexposed areas)

0. Reddish1. Pale2. Olive3. Brown4. Dark Brown
Freckles (unexposed areas)

0. Many1. Several2. Few3. Rare4. None
Face sensitivity to sun

0. Very sensitive1. Sensitive2. Sometimes3. Resistant4. Never a problem
Do you turn brown?

0. Never1. Seldom2. Sometimes3. Often4. Always
How brown do you get?

0. Never1. Light tan2. Medium tan3. Dark tan4. Deep Dark tan
How often do you tan?

0. Never1. Seldom2. Sometimes3. Often4. Always
If overexposed to sun

0. Painful blisters, peeling1. Mild blisters, peeling2. Burn, mild peeling3. Rarely burn4. No burning
When was your last tan?

0. More than 3 months ago1. 2 - 3 months ago2. 1 - 2 months ago3. 1 - 4 weeks ago4. Within the last week
Your Skin Score Is:
Click on the image which best represents your Skin Type (below):

Select your Skin Type below:

	Skin Score	Skin Type	Characteristics
0
1
2
3
4

Please select YES or NO to the following questions & provide information as required:
1. MEDICAL ILLNESSES: Do you have ANY current or chronic medical illnesses as listed below? (Heat urticaria, diabetes, autoimmune disorders or any immunosuppression, blooddisorders, cancer, bacterial or viral infections, medical conditions that significantlycompromise the healing response, skin photosensitivity disorders, hormone imbalance, thyroid imbalance, raised scarring (keloid), or any other condition or illness.)

YesNo
If yes, please list:
2. YOUR SKIN: Do you have ANY current or chronic skin conditions? Allergies?

YesNo
If yes, please list:
3. DOCTOR’S CARE: Are you currently under a doctor’s care?

YesNo
4. HOSPITALISATIONS: Have you been hospitalised for illnesses / other:

YesNo
5. LIST MEDICATIONS OF ALL TYPES: (Prescription and non-prescription, vitamins, herbal, natural supplements, steroids of any kind, blood thinning medication, Accutane, tanning products oral or injectable, birth control pill, hormones, others?)

YesNo
If yes, please list:
6. ALLERGIES: Do you have ANY allergies to medications, foods, latex, Aspirin, Lidocaine, Hydrocortisone, Hydroquinone or skin bleaching agents or other substances?

YesNo
If yes, please list:
7. WOMEN: Are you trying to conceive, or are you pregnant?

YesNo
8. WOMEN: Are you breastfeeding?

YesNo
9. SCARRING HISTORY: Please show us your scars, so we can make an assessment of keloid or hypertrophic symptoms.

YesNo
10. SEIZURES: Do you have a history of light induced seizures?

YesNo
11. In the last three (3) months, have you used any of the following products? (Glycolic acid or other alpha hydroxy or beta hydroxy acid products; exfoliating or resurfacing products or treatments, or Retin A on a tattoo, or Tretinoin in the last 6months on a tattoo?)

YesNo
If yes, please list:
12. TANNING HISTORY: Have you had any unprotected sun exposure, used tanning creams (including sunless tanning lotions) or tanning beds or lamps in the last 4-6weeks?

YesNo
13. BLOOD DISORDERS: Do you have hepatitis, blood thinning, AIDS?

YesNo
14. MOLES: Do you have any moles or suspicious spots under your tattoo?

YesNo
Contraindications:

Therapy using the ND YAG - Q Switch laser for tattoo removal is contraindicated for those clients who have any of the following conditions. Please circle the appropriate answer below and sign the form at the bottom. This is to ensure the best outcome of your sessions, so please be sure to read the form carefully.
Are you hypersensitive to light in the near infrared wavelength region?

YesNo
Do you take medication which is known to increase sensitivity to sunlight?

YesNo
Have you taken oral isotretinoin, such as Accutane®, within the last six months?

YesNo
Do you have an active localised or systemic infection, or an open wound in the area being treated?

YesNo
Do you have a significant systemic illness or an illness localised in the area being treated e.g. lupus?

YesNo
Do you have common acquired nevi that are predisposed to the development of malignant melanoma?

YesNo
Do you take medications that alter the wound-healing response? (These may interfere with post-session healing and may require special precautions.)

YesNo
Do you have a history of healing problems or history of raised scarring (keloid) formation? (It may not be a feasible to conduct laser tattoo removal.)

YesNo
Do you have a history of skin cancer or suspicious lesions that you are concerned about? (It may not be a feasible to conduct laser tattoo removal.)

YesNo
Do you have a history of erythema ab igne, which is a persistent skin rash produced by prolonged or repeated exposure to moderately intense heat or infrared irritation?

YesNo
Do you have hyperpigmentation (darkening of the skin) or hypopigmentation (lightening of the skin) or marks after physical trauma?

YesNo
Have you had chemical or mechanical epilation within the last six weeks? (It may interfere with the post-session healing process.)

YesNo
Informed Consent for Laser Tattoo Removal
As a client you have the right to be informed so that you may make the decision whether to proceed with Laser Tattoo Removal or decline after knowing the risks involved. This disclosure is to help to inform you about the risks, side effects and possible complications related to laser tattoo removal prior to your consent.
I give full consent to and authorise White Diamond Laser and members of their staff to perform multiple laser procedures and related services on me. The procedure planned uses laser technology for the removal of tattoos.

I am undertaking the procedure and I am prepared to take full responsibility upon myself for this procedure and all the associated risks and release White Diamond Laser from all liability at all times.

I understand that all Laser procedures may have side effects.

The following side effects may occur with the tattoo removal system:

1. Possible side effects of the procedure include but are not limited to pain, purpura, swelling, redness, bruising, blistering, crusting/scab formation, ingrown hairs, infection, hot sun burnt feeling and unforeseen complications which can last up to many months, years or permanently.

2. Scarring is uncommon but it is a risk, and can be hypertrophic or even keloid, other skin texture and colour changes may occur, and other unforeseen complications may present which can last up to many months, years and may be permanent.

3. Short term effects may include reddening, mild burning, temporary bruising or blistering. A brownish/red darkening of the skin (known as hyperpigmentation) or lightening of the skin (known as hypopigmentation) may occur. This usually resolves in weeks, but it can take up to 3-6 months to heal. Permanent colour change is a rare side effect. Loss of freckles or pigmented lesions can occur.

4. Textual and/or colour changes in the skin can occur and can be permanent. Many of the cosmetic tattoos and body tattoos are made with iron oxide pigments. Iron oxide can turn red-brown or black. Titanium oxide and other pigments may also turn black. This black or dark colour may be un-removable. Because of the immediate whitening of the exposed treated area by the laser, there can be a temporary obscuring of ink, which can make it difficult or impossible to notice a specific colour change from the tattoo removal process. If this reaction occurs during a removal, I assume all responsibility. Other options for Tattoo removal - include cosmetic surgery, consultations with dermatologists.

5. Infection following laser tattoo removal is unusual however, bacterial, fungal and viral infections can occur. Herpes simplex virus infections around the mouth can occur following a session. This applies to both individuals with a past history of herpes simplex virus infections and individuals with no known history of herpes simplex virus infections in the mouth area. Should any type of skin infection occur, I will immediately seek medical advice, and understand that additional treatment or medical antibiotics may be required.

6. Pinpoint bleeding is rare but may result following procedures. Should bleeding occur, additional treatment may be necessary.

7. Hypersensitivity to the various tattoo pigments during the tattoo removal process may occur, especially if the tattoo pigment contained mercury, cobalt or chromium. Upon dissemination, the pigments can induce a severe allergic reaction that can occur with each successive application. Noted in some clients are superficial erosions, bruising, blistering, milia, redness and swelling which can last up to many months, years or permanently.

8. Some medications and suntans prohibit the laser tattoo removal process. Persons on Accutane and photosensitising medications cannot be treated and if you have suntanned within the last 6 weeks or have a spray/synthetic tan you cannot be treated.

9. Compliance with the aftercare guidelines is crucial for healing, prevention of scarring, and hyperpigmentation. Aftercare guidelines include avoiding the sun for 2 months after the procedure. If it is necessary to be in the sun, a sunscreen with SPF 50 or greater must be used.

10. I understand the nature and purpose of laser tattoo removal and it has been fully explained to me. I have read and understand this agreement. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement. Alternative methods of tattoo removal and the risks and benefits
of laser tattoo removal have been explained to me and I understand that I have the right to refuse to undergo laser tattoo removal.

11. I understand that multiple sessions will be necessary to achieve desired results. No guarantee, warranty or assurance has been made to me as to the results that may be obtained. I understand results vary from person to person and that complete tattoo removal is not always possible.

12. I give full permission for a photo (s) of my tattoo to be taken by White Diamond Laser.
Waiver for Laser Tattoo Removal
Ink Type / Waiver of Post Procedural Outcomes.
1. How old is your Tattoo?
2. Is your tattoo a professional tattoo?

YesNo
3. Is your tattoo a tattoo cover-up?

YesNo
4. Is your tattoo a cosmetic tattoo?

YesNo
5. Have you tried any other methods of Tattoo removal?

YesNo
If yes, please describe results below:
6. Have you had laser tattoo removal before?

YesNo
If yes, please describe results below:
7. Do you have a suntan?

YesNo
I certify that the preceding medical, personal and skin history statements are true and correct. I am aware that it is my responsibility to inform White Diamond Laser of my medical or health conditions and to update this history.

I have had the full process explained to me and I fully understand what is involved. I have read and received a copy of the aftercare instructions. My questions regarding the procedure have been answered satisfactorily. I understand the procedure and accept all risks. I hereby release White Diamond Laser and all White Diamond Laser staff from all liabilities associated with my procedure.

I understand that tattoos are an art form meant to last a lifetime. I have read the Fact Sheet and understand it fully. I have read and understood the Informed Consent and Waiver Forms and signed both forms. I understand that no warranties, no guarantees, no refunds, and no forecast as to the number of removal sessions required can be given, and that no outcomes of each session can be given.
Client Name:
Signature

Clear
Date

DayMonthYear
Date
Fact Sheet for Laser Tattoo Removal
1. Placement of Tattoo pigment:
The tattoo pigment has been placed into the dermis, the layer of skin under the epidermis, where the large particles cannot be absorbed and are permanent.

2. How the laser works:
The Laser sends energy into the dermis and this energy is absorbed by the tattoo pigment which breaks up into tiny particles which can then be absorbed by the body.

3. Elimination:
The fragmented ink particles are eliminated through the body’s lymphatic system. In addition some pigment may be lost through the surface of the skin via scabbing or blistering. If someone smokes more toxins are circulating in the lymphatic system and elimination of the pigment particles can take longer. A healthy person drinking lots of water and exercising eliminates ink particles faster.

4. Number of Sessions Required:
This depends on each individual and factors include: elimination rate, the tattoo location and pigment colour. Only the top layer of pigment can be treated at any one time somewhat like the skin of an onion. The number of sessions required can vary greatly in number from 3 to 6 and up to 10+ may be required for difficult colours. It is not possible to accurately assess how many sessions will be needed for an individual tattoo.

5. Results:
Results can be complete tattoo removal or just fading of the tattoo. Some people only require the tattoo to be faded so that they can have a cover-up tattoo.

6. Pain:
Laser energy is very powerful and hits the ink pigment at nanosecond speed (one billionth of a second). The fragmenting of the pigment may hurt and is compared to the sting from a rubber band. Depending on the size of the tattoo being treated, a removal session can be as little as five minutes or longer for larger tattoos and to decrease discomfort your technician may recommend the use of a skin numbing cream such as a topical anaesthetic.

7. Appointment Scheduling:
The time between appointments can vary for each individual as it depends on the body’s reaction to the laser and it is likely that your sessions will be scheduled for between 4 to 8 week intervals or as advised by your technician. Your technician will book your next appointment.

8. Possible Side Effects:
Following your laser session, you may experience redness, swelling, scabbing, pinpoint bleeding and sometimes blistering or whitening of the tattoo pigment which returns to normal over time. Please see the Informed Consent for Laser Tattoo Removal information sheet for complete details.

9. Aftercare Advice:
To avoid any complications please follow the aftercare advice on the Aftercare for Laser Tattoo Removal information sheet provided.
Aftercare for Laser Tattoo Removal
After your procedure, you may experience some redness, swelling and scabbing and sometimes blistering. This is a normal process as the body works to eliminate the tattoo pigment. As advised, the fragmented pigment is removed internally by scavenger cells within your body. An antiseptic powder and a dressing will be applied following your procedure.

Aftercare:
- Following your treatment, the skin will be cooled
- MediPulv Antiseptic Powder will be applied to the treated area
- Please leave the non-stick dressing on the skin for 24-48 hours
- Avoid excessive heat in the skin (exercise, hot bath, shower, sauna for 24-48 hrs.)
- Do not expose the treated skin to the sun
- Use SPF 50+ when in the sun as well as protective clothing
- Do not pick or scratch the treated skin
- Avoid injury to the treated skin
- Once the treated area has returned to normal, apply MediCreme twice daily
- The treated area may feel slightly sunburned for a few days and cold packs can be applied for comfort
- The treated skin may remain red and puffy for up to a few weeks
- It’s common to develop an itching sensation in the area even weeks after a removal session
In case of:
- If there is any crusting or oozing from the treated area, continue applying MediPulv after cleansing and cover with a bandage. Keep the treated area covered 24 hours a day until all crusting is gone.
- If blisters form, which is not unusual in early sessions or when your tattoo was a cover-up, do not puncture them. Let them reabsorb or break naturally and keep covered with MediPulv and a bandage.
- Do not pick any crusting or scab as you may cause scarring.
- Avoid swimming or using hot tubs until the skin has returned to normal.
- Should you experience increasing pain, redness, oozing or develop a temperature over 38ºC, after the first two days, please call your doctor immediately
Should be Empty:

Medical History Form for Laser Tattoo Removal

Please select YES or NO to the following questions & provide information as required:

Informed Consent for Laser Tattoo Removal

Waiver for Laser Tattoo Removal

Fact Sheet for Laser Tattoo Removal

Aftercare for Laser Tattoo Removal