Laser Tattoo Removal Consultation & Consent Form

Safely fades unwanted tattoos using advanced laser technology for clear, confident skin. Start your removal journey today!

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Client Information

Title Mr.Mrs.MissMs. Full Name Date * Address Phone Email * Date of Birth Emergency Contact

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Medical Information

Please list all medications that you take regularly (including hormones, vitamins, etc.) Have you taken blood thinners or anti-coagulants in the last 3 months? YesNo If Yes, please provide details Allergies Are you currently under doctor's care? YesNo If Yes, please provide details Do you smoke? YesNo If Yes, how many per day? Are you on HRT (Hormone Replacement Therapy)? YesNo

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Tattoo Information

Location of Tattoo(s) Is the Tattoo: ProfessionalAmateurTraumaticSurgical Details Have you had any of the following in the tattoo area? Chemical PeelDermabrasionLaserSurgeryOther If Other, specify Do you have permanent makeup, implants or injectables (Filler/Botox) in the treatment area? YesNo Details Have you had any fake or natural tan recently? YesNo Details How did you hear about us?

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Medical History

Please tick any health conditions that you have had or are currently experiencing.

Heart rhythm disturbanceHaemophiliaThyroid disordersCancerHepatitisDiabetesPacemaker / Defibrillator or electronically implanted devicesHormonal disordersRecent surgeryMetal plates / PinsSurgery within the last 1 yearLupusRoaccutane (within last 6 months)HypoglycaemiaPhlebitisEczema or PsoriasisAutoimmune diseaseHIVThrombosisBlood clotting disorderRecent illnessMultiple sclerosisEpilepsy

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Kirby-Desai Scoring

Skin Type Analysis

How would you rate your skin in the treatment area? Type I - Always burns, never tans. Extremely fair skin, blonde hair, blue/green eyes.Type II - Usually burns, tans less than average. Fair skin, sandy brown/brown hair, blue/green eyes.Type III - Sometimes burns, gradually tans. Medium skin, brown hair, green/brown eyes.Type IV - Sometimes burns, tans easily. Olive/light brown skin, dark brown hair and eyes.Type V - Rarely burns, tans profusely. Dark brown skin, black hair and eyes.Type VI - Deeply pigmented, never burns. Black skin, black hair and eyes.

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Location of Tattoo

Head & NeckUpper TrunkLower TrunkProximal ExtremityDistal Extremity

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Colour(s) of Tattoo

Black onlyMost Black, Some RedMost Black, Some Red & Other ColoursMultiple Colours

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Amount of Ink

AmateurMinimalModerateSignificant

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Scarring & Tissue Change

No ScarMinimal ScarringModerate ScarringSignificant Scarring

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Tattoo Layers

NoYes Total Points

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Test Patch - Test 1

Area NM J/cm² Result Notes

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Test Patch - Test 2

Area NM J/cm² Result Notes

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Test Patch - Test 3

Area NM J/cm² Result Notes

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Client Treatment Report

Date of Treatment Clinician Name Clinician Signature Treatment Area Settings Used Amount Paid Payment Details Comments

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Medical Informed Consent

I consent and authorise Glemz Hair & Beauty to perform laser tattoo removal on me. I understand the following points and have had the opportunity to ask questions during my consultation.

I understand that:

Treatment is successful for most clients; however, individual results cannot be guaranteed. Most clients require 8–10 treatments to achieve up to 80% pigmentation reduction. Some may require additional treatments depending on individual factors. Darker skin types may require additional treatment sessions. I will avoid UV exposure and use SPF 30+ sunscreen throughout my treatment course. I have received information regarding home care, treatment procedures, possible side effects and associated risks.

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Risks Associated with Laser Tattoo Removal

I understand pigment changes (lightening or darkening of the skin), blistering, burns, infection, bruising, swelling, scabbing, itching, pain, dry skin and, in rare cases, scarring may occur. I understand allergic or delayed inflammatory reactions may occur and that a test patch may be performed. I understand protective eyewear must be worn throughout the procedure to prevent eye injury. I consent to clinical photographs being taken to monitor treatment progress. Photographs identifying me will not be used without my permission. I understand laser tattoo removal can be uncomfortable and sometimes painful. I understand lighter tattoo colours such as white, yellow, orange and light green may not respond to treatment. I confirm that I am 18 years of age or older, or that a parent/guardian is providing consent. I agree to inform the clinic of any changes to my health or medications during my treatment course. I understand there are no refunds for treatments already performed.

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Pre-Treatment Declaration

Please confirm the following:

I have not had unprotected sun exposure, used tanning beds or fake tan within the last 4 weeks. I have no history of seizures and have disclosed all known allergies. I am not taking medications that cause photosensitivity (including St John's Wort), unless disclosed. I do not have a history of keloid or hypertrophic scar formation. I do not have any active infection or immunosuppression. I do not have open wounds or lesions in the treatment area. I do not have active Herpes Simplex I or II in the treatment area. I have not used topical tretinoin (Retin-A/Renova) within the last 2 weeks. I have not had laser resurfacing within the last 6 months. I have not had a chemical peel within the last 4 weeks. I have not used oral Isotretinoin (Accutane) within the last 6 months. If I have diabetes, I have informed my clinician. I am not pregnant. I have received the pre-treatment and post-treatment care instructions and agree to follow them. I understand and agree to the clinic's cancellation policy.

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Parent / Guardian Consent (Required if under 18 years of age)

Parent / Guardian Full Name Parent / Guardian Signature

Clear

Date

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