Laser Tattoo Removal Consent Form

Laser Tattoo Removal Consent Form

Patient Information
Full Name*

First NameLast Name
Date of birth*

MonthDayYear
Date
Gender*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Email*
example@example.com
How did you hear about us?*

CLIENT INFORMATION AND MEDICAL HISTORY

Welcome! We are looking forward to your first visit.
Personal History
Name*

First NameLast Name
Date of birth*

MonthDayYear
Date
Age*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Work Phone Number

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

First NameLast Name
Phone Number*

Area CodePhone Number
Which of the following describes your skin type?*

Type I - Always burns, never tansType II - Always burns, sometimes tansType III - Sometimes burns, always tansType IV - Rarely burns, always tansType V - Brown, moderately pigmented skinType VI - Black Skin
TREATMENT HISTORY
Have you ever had laser Tattoo removal?*
Have you had any recent tanning or sun exposure that changed the color of your skin?*
Have you recently used any self tanning lotions or treatments? *
Do you form thick or raised scars from cuts or burns?*
Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma?*
Female Clients
Are you pregnant or trying to become pregnant?*
Are you breastfeeding?*
Are you using contraception?*
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 the technician. esthetician, therapist, doctor or nurse of my current medical or health conditions and to update this history. A current medical history is essential for the caregiver to excute appropriate treatment procedures.
Date*

MonthDayYear
Date
Signature*

Clear

Client Treatment Consent And Release
I acknowledge that beauty treatments, the practice of skin care, and the practice of massage, including, but not limited to, microablation, microdermabrasion, waxing, electrolysis, facial toning, permanent cosmetics, body treatments, ionization, laser treatments, tattoo removal, vin treatments, brown spot removal, BOTOX, Collagen, Dermal Fillers, Sclerotherapy, Mesotherapy, Dermaplaning, and various other beauty procedures is not an exact science and no specific guarantees can or have been made concerning the outcome. I understand that some clients experience more change and improvement than others. In virtually all cases, multiple treatments are required in order to realize a difference.

I also understand and agree to assume the following risks and hazards which may occur in connection with any particular treatment including but not limited to: unsatisfactory results, soreness, poor healing, discomfort, redness, blistering, nerve damage, scarring, infection, change in skin pigmentation, allergic reaction, muscle damage, and increased hair growth. I understand that even tough precautions may be taken in my treatment, not all risks can be known in advance.

Given the above, I understand that response to treatment varies on an individual basis and that specific results are not guaranteed. Therefore, in consideration for any treatment received, I agree to unconditionally defend, hold harmless and release from any and all liability the company and the individual that provided my treatment, the insured, and any additional insureds, as well as any officers, directors, or employees of the above companies for any condition or result., known or unknown, that may arise as a consequence of any treatment that I receive.

I have fully disclosed on my client intake form any medications, previous complications, or current conditions that may affect my treatment. I understand and agree that any legal action of any kind related to any treatment I receive will be limited to binding arbitration using a single arbitrator agreed to by both parties.
Date*

MonthDayYear
Date
Signature*

Clear

Salon Policies
We respect your time and we are glad you choose Laser Flavor / Flavor Beauty Bar for your beauty needs. We've created the polices listed below to provide you with versitily and convenience to our guests. When booking a reservation/appointment that is your acceptance of our policies. Make sure that you have reviewed and agreed to the terms listed below.

Please respect our schedule by keeping appointments whenever possible and providing a minimum of 24 hour notice when canceling or rescheduling your appointment. Failure to comply with these guidelines will result in a loss of treatment or a $25 rescheduling fee.

Loss of treatment or $25 Rebooking fee will be charged in the following circumstances:

- Less than 24 hour notification to cancel or reschedule

- No show or missed appointment

- Late Arrival - late arrival May result in your appointment being cancelled or shortened with full charges applied. We will only be able to accommodate you if our schedule allows.

Policies

- We have a no refund policy, however we will consider an exchange for other services at our discretion.

- Vouchers are accepted from NEW CLIENTS ONLY. Vouchers from existing clients will not be redeemed.
Date*

MonthDayYear
Date
Signature*

Clear

Treatment Instructions
Treatment Instructions
The purpose of this procedure is to diminish or remove unwanted Tattoo(s). The procedure requires more than one treatment and may produce permanent tattoo removal. The total number of treatments will vary between individuals. On occasion there are patients that do not respond to treatments. Treatment duration varies from 1-20 minutes depending on the size of the area.

1. Avoid the sun 2-4 weeks before and after treatment.
2. Hair must be shaved in the treatment area 12-24 hours prior to any hair removal procedure.
3. Avoid deep tanning, including tanning beds and tanning creams 2 weeks before and a 1 week after treatment. If you must go in the sun use a sunscreen of SPF 25 or higher.
4. If throughout the course of your treatment, you need to take any photosensitizing medication and/or antibiotics, we will not be able to treat you within 10 days of your last dose.
5. We ask that you arrive to your treatment with no lotions, sprays or creams in the treatment area.
6. A minimum of 8 weeks in between treatments is required to achieve maximum results, depending on the area.
Post Treatment Instructions
1. Immediately after your treatment there may be some redness and bumps ate the treated area which may last about 2 hours or longer. It is normal for the treated area to feel like its been sunburned for a few hours. You can use a cold compress if needed. It is also recommended that you use aloe vera gel. Darker pigmented people may have more discomfort and may need to use aloe vera longer.*

I Understand
2.Avoid sun exposure to reduce the chance of light or dark marks for 2 months. Use sunscreen with a SPF 25 or higher during the course of your treatments and 1-2 months following the treatment.*

I Understand
3. Avoid picking or scratching the treated area.*

I Understand
4. You can shower after the laser treatments. Make sure you use mild soap and pat dry the treated area. Deodorant can be used after 24 hours.*

I Understand
5. Call us and/or your physicians office with any concerns you may have after treatment.*

I Understand
Date*

MonthDayYear
Date
Signature*

Clear

Laser Tattoo Removal Consent Form

CLIENT INFORMATION AND MEDICAL HISTORY

Medical History

Salon Policies

Informed Consent

Treatment Instructions

Laser Tattoo Removal Treatment Questionaire