Saline Removal Consent Form

Saline Removal Consent Form
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Email*
example@example.com
Emergency Contact*

Full NameCell Number
It is very important that you read ALL of the information in this document, sign it, and send it back to us. This confirms that you understand our policies.

Contraindications - You may not a candidate for saline removal if any of the following apply to you:

- Pregnancy/nursing
- Sensitive skin
- Diabetes Type 1
- Lupus
- Hepatitis B/C
- AIDS
- Active skin disorders: cold sores, shingles, impetigo, psoriasis, pink eye, sun burn, severe acne, breakouts/pimples in the area to be treated
- Active vitiligo
- Severe rosacea
- Blood Disorders: sickle cell, hemophilia
- Heart transplant
- Keloid formation
- Mental disorder (must be controlled)
- Accutane/Tretnoin (must be off for 6 months)
- Steroids (must be off for 6 months)
- Sickness/illness: cold, flu, sinus infection, etc.
Click Yes to acknowledge the following statements:
The nature and method of the proposed saline removal procedure has been explained to me including risks 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 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.*

Yes
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.*

Yes
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.*

Yes
I understand there are medical options available for pigment removal. I have decided to decline those methods.*

Yes
I understand that the unwanted pigment may not be successfully lightened to the point that it can no longer be seen, and that scarring as hyper-pigmentation or hypo-pigmentation, or other damage to the skin, which may be permanent, may occur during the process. I will not hold my technician and/or the distributor of tattoo removal products used in this attempted tattoo lightening or removal, liable for any damages that may occur to my person.*

Yes
Which of the following best describes your skin type?*

Always burns, never tansAlways burns, sometimes tans III. Sometimes burns, always tansRarely burns, always tansBrown, moderately pigmented skinBlack skin
For skin types V and VI only and saline removal only:
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.*

Yes
I understand that lightening tattoo pigment is difficult, if even possible. As a result I will not hold my technician or this establishment responsible for any resultant failure to lighten the unwanted pigment.*

Yes
I agree to submit to before and after photographs, and give my permission to use such photographs for publication and/or for teaching purposes.*

Yes
I agree to follow all aftercare instructions.*

Yes
I have been duly informed of the nature, risks, possible complications and consequences as listed above. I further understand that my technician is not a medical doctor.*

Yes
I understand all information listed above, have had my questions answered, and agree to all conditions and provisions of this document as evidenced by my signature below. I accept the risks for having this procedure done.*

Yes
Our Policies

Please take a moment to complete our consent form. By submitting the form below you agree to knowingly and willingly consenting to our policies and procedures.
24- hour notice is required for any canceled or rescheduled appointment or up to 100% of service price will be charged. Failure to show without notice will require in full payment of service booked. We do not offer monetary refunds on services rendered. We do have a 7-day policy in place on services in which a client can come back and have corrections made. Client must contact provider within 24-48hours after service rendered of any issues. Fees may apply. By choosing yes, I’m acknowledging I have read, understand, and agree with the terms of these policies.*

Yes
Signature (Signature applies to consent to the process during the agreed treatment plan period)*

Clear
Should be Empty:

Saline Removal Consent Form

Our Policies