LASER TATTOO REMOVAL CONSULTATION

AND CONSENT FORM

Please answer the consultation questions appropriately. This questionnaire will guide us for your upcoming treatment.

Medical History

Consent and Acknowledgment

To perform laser tattoo removal on me. I understand the following points and have had the opportunity to ask questions during my consultation.

  • Treatment is successful on most clients but my individual results cannot be guaranteed.

  • Most clients require 8 – 10 treatments to achieve up to 80% pigmentation reduction, some may require more. Outcome will vary and

    individual results depend on many factors, thus it is extremely difficult to advise on exact number of treatments required.

  • Darker skin type clients will require additional treatments.

  • Exposure to UV Rays will compromise my treatment, therefore I will use SPF 50+ sunscreen.

  • Home care requirements.

  • Treatment process.

  • Side effects.

Risks associated with laser tattoo removal:

Even though the risk of complication is extremely low, the following can occur:

  • Pigment changes (light or dark spots on the skin) lasting 1 – 6 months. Freckles may temporarily or permanently disappear in treated areas.

  • Other potential risk includes crusting, itching, pain, bruising, pimple-like bumps, dry skin, hypopigmentation (lightening of the skin),

  • hyperpigmentation (darkening of the skin), blistering, burns, infection, scabbing, swelling, a very small risk of scarring and a failure to achieve the desired result.

  • Allergic or delayed inflammatory reactions can develop. A test patch is performed to ascertain reaction of the skin.

  • Laser can cause eye injury and protective eyewear must be worn during treatment.

  • I confirm I not had unprotected sun exposure (including tanning beds and fake tan creams) in the last 4 weeks.

  • I have no history of seizures and I have disclosed all known allergies (e.g. latex, etc.).

  • I am not taking medications causing photosensitivity (prescription/non-prescription) e.g. St John’s

  • I do not have a history of keloid and hypertrophic scar formation.

  • I do not have active infections/immunosuppression.

  • I do not have open lesions in the areas to be treated.

  • I do not have herpes I or II – in the areas to be treated.

  • I have not used tretinoin (Retin – A, Renova) within the last 2 weeks.

  • I have not had laser resurfacing within the last 6 months.

  • I have not a chemical peel – within the last 4 weeks.

  • I have not used oral isotretinoin/Accutane – within the last 6 months.

  • I have advised my clinician if I am diabetic.

  • I have received the Pre- and Post-Care Information Sheet. I agree to adhere to all these recommendations.

  • I understand the laser tattoo removal treatment is uncomfortable and may be quite painful.

  • I understand lighter coloured inks, such as white, yellow, orange and lighter green, will be ineffective.

  • I will advise (salon) of any changes that occur during my treatment that can increase potential risks or reduce efficacy.

  • I am 18 years or over.

  • I understand that there is no refund for any of the services performed.I am fully aware that this procedure is made voluntarily, and I have had the opportunity to ask questions and have them answered to my satisfaction.

  • I have been informed about the aftercare instructions and commit to following them diligently.

  • I release the practitioner and the establishment from liability if any complications or unfavourable results arise from the treatment.

  • I understand the costs associated with this procedure and accept full responsibility for these costs.

  • I certify that I have voluntarily sought the services provided and consent to the treatment.

Clear