Tattoo Lightening Consent Form

The following confidential medical information will be property of The Artistry L.L.C. This is required for the benefit and safety of the client in obtaining any and all procedures performed by The Artistry L.L.C Please read and fill out the information carefully. We hope your experience will be a pleasant one and we thank you for your cooperation.

Name*

First NameLast Name

Date of Birth*

Date

Phone*

Email*

example@example.com

Address*

Address

Street Address Line 2

City/State/Zip

How did you hear about us?

Are you Pregnant, Nursing or Lactating?

I am over the age of 18 and in sound mind, body and health

Do you take Asprin daily?

Have you ever had a cold sore, fever blister or prior history of herpes?

Are you allergic or have any sensitivity to Latex?

Have you had a chemical peel in the last 6 weeks? If yes, please contact us to reschedule your appointment.

Have you had any injectable fillers such as Botox, Restylane, Juvederm, etc? On or near the treated area in the last 2 weeks? If yes, please contact us to reschedule your appointment.

Have you had any complications with previous Permanent makeup or tattoos?

Are you currently undergoing radiation or chemo therapy?

Are you Anemic?

Do you bruise easily?

Do you heal slowly or have complications with healing?

Do you have any allergies to metal?

Do you have any allergies to products containing "Caine"? ie., Lidocaine, etc.

Do you have any allergies to epinephrine?

Do you have a history of skin diseases?

If yes, explain.

PLEASE CHECK IF YOU HAVE A HISTORY OF ANY OF THE FOLLOWING CONDITIONS:

Other medical conditions, current prescription or over the counter medications currently taking*

I, currently have an unwanted tattoo. This pigment is located on (area of the body) . This area was last tattooed on Date This procedure was tattooed (number of times) .

This pigment is unwanted because (indicate: shape, color, location)

I would like the technician to attempt to:

Remove the tattoo if possiblePartially remove the tattooLighten the tattooOther

I understand that several treatments WILL be needed in order to attempt to achieve my desired results. I have not been given any guarantees as to how much pigment will actually be removed from the skin.

I understand that the unwanted pigment may not be successfully removed, and (in a rare case) that permanent scarring can result in an attempt to remove the pigment, as well as possible hyper- pigmentation, hypopigmentation, or other damage to the skin, which may be permanent.

I understand there are other options and methods available for pigment removal/lightning. I have decided to move forward with the Saline removal/lightning.

I will not hold The Artistry L.L.C or it’s Practitioners and/or the distributor of tattoo removal products used in this attempted tattoo removal, liable for any damages that may occur to my skin.

I agree to take “before” and “after” photographs and agree to the use of advertising, marketing across all social media platforms and website.

I agree to follow all aftercare instructions. To conform to all rules and regulations established by The Artistry L.L.C and it’s Practitioners, to ensure a successful removal/lightening of the unwanted pigment/tattoo.

I have been informed of the nature, risks, possible complications and consequences as listed above. I further understand that The Artistry L.L.C and it’s Practitioners are not a medical doctor and this procedure is an art and not an exact science and have neither asked for nor received any guarantees or promises as to the results obtained.

I acknowledge by signing this consent form, I have been given the full opportunity to ask any and all questions about saline removal/lightening procedure(s), it’s process, and the risk involved from The Artistry L.L.C and it’s Practitioners. The decision to have saline removal/lightening procedure(s) performed is my own and I understand and accept all risk involved, therefore releasing The Artistry L.L.C and it’s Practitioners from any liability. The Artistry L.L.C Practitioners are artist and highly trained, experienced and skilled artist and makes no claims to anything more. Saline removal/lightening is not a medical procedure.

NO REFUNDS......NO EXCEPTIONS.

I release The Artistry LLC and technicians from all liability associated with this procedure, which is performed with the utmost attention to safety and proper application. This agreement will remain in effect for this procedure and all future procedures conducted by my technician.

DIGITAL FORM SUBMISSION IS ACCEPTANCE OF TERMS OF SERVICE

Signature

Name

First NameLast Name

Date

Informed Consent & Release Form