Glam Body Sugaring Boutique Dermaplaning Consent

Name

First Name Last Name

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Phone Number

Area Code Phone Number

Email

example@example.com

Date of Birth

Date

Tattoo Size?

Tattoo Age?

Was this tattoo previously covered up?

Tattoo Location?

Tattoo Condition?

Any previous attempts of removal of this tattoo? (laser, creams, self removal) If YES, provide details:

Does this tattoo have any signs of scarring? (raised, shine, different texture)

Skin Type: Caucasian, Asian, African American, Latin, other

Do you hyper pigment when you scar?

Do you have any hypertrophic scars?

Do you hypo pigment when you scars? (scar turns white)

Do you scar easily?

Do you take any medications? If yes, please list:

List any and all allergies:

Do you have any of these conditions? Eczema, Psoriasis, Acne, Skin Cancer, Vitiligo, Rosacea, Dermatitis

Do you have any of the following conditions? Heart condition, heart murmur, Pace Maker, High Blood Pressure, low Blood Pressure, HIV, Hepatitis B/C, Hemophilia, leukemia, Asthma, Diabetes, Epilepsy. If YES, please detail:

Tattoo Removal Consent Form

I currently have an unwanted tattoo/permanent makeup. This tattoo is located on the _______________________ (area of the body). This area was last tattooed on ________________________(approximate date) by ________________________ (business or tecnhnician). The permanent makeup is unwanted because ___________________________________________________ (indicate shape, color,location). I would like my technician today to A.___ Remove the entire tattoo if possible B.____ Partially remove the tattoo (place an X where applicable.

I understand that several treatments may be required in order to try to achieve my desired result.I have not been givem any guarantees as to the quality of the removal results.

I understand there are many medical and esthetic options fo the removal of my tattoo or permanent makeup. I have decided to choose the Rejuvi removal technique at this time.

I understand the unwanted tattoo/permanent makeup may not be successfuly removed and that permanent scarring may result in the attempt to remove the unwanted tattoo/permanent makeup as well as hypertrophy and hypo-pigmentation or other damage to the skin which may be permanent.

I understand that removing tattoo/ permanent makeup is a difficult and complicated process. As a result, I will not hold the technician at Glam Body Sugaring Boutique,LLC responsible in any resultant failure to remove partially or fully.

Furthermore, I will Not hold the Business or technician, the distributor or manufacturer of the tattoo removal products used in the attempted tattoo remova/permanent makeup process, liable for any damages that may occur to my face or body.

I agree to photographs "before" and "after' to be taken and to conform to all rules and regulations established by the technician and business listed for unwanted tattoo/permanent makeup removal. I agree to follow all aftercare instructions.

I have been duly informed of the nature, risks, possible complications, and consequences listed above. I also understand that the above listed technician is not a medical doctor,and have neither asked nor received any guarantees or promises as to the results obtained.

I understand everyting listed above, have had all my questions answered,agree that it is all true and correct and by my signature below, I agree to the above.

Cancellation/ Rescheduling/ No Show Policy

CANCELLATION/ NO SHOW/ LATE ARRIVAL POLICY

We understand that unplanned issues can come up and you may need to cancel an appointment. If that happens, we respectfully ask for scheduled appointments to be cancelled at least 48 hoiurs in advance. Our staff wants to be available for your needs and the needs of all of our clients. When a client does not show up for a scheduled appointment, another client loses an opportunity to be seen and the Esthetician loses the opportunity to make income.

Although we have always had a cancellation policy, circumstamnces have called for us to enforce a policy for charging for no show appointments and those appoiintments not cancelled 48 hours before your scheduled appointment.

We do thank you for being a valued client, and for your understanding and cooperation.

As of September 1, 2015 the folowing fees will be implemented:

You may cancel your appointment without charge up to 48 hours before your scheduled appointment.

Same day Cancellations will be charged 50% of the scheduled service price.

No call or No Show will be charged 100% of scheduled service price.

Thank you for taking the time to complete this form. Please sign below.

Signature

Clear

Glam Body Sugaring Boutique Tattoo Removal Consent Form