Consent Form

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Laser Tattoo Removal Consultation& Consent Form

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

Title

Mr. Mrs Miss Ms

Name:

Date:

Adderss:

Phone:

E-mail:

DOB:

Emergency Contact:

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?

Yes No

Details

Allergies

Are you currently under doctor's care?

Yes No

Details

Do you smoke?

Yes No

If so, how many per day?

Are you on HRT? (Hormone replacement therapy)

Yes No

Location of Tattoo/s:

Is the Tattoo:

Professional Amateur Traumatic Surgical

Details:

Have you had (in Tattoo Area):

Chemical Peel Dermabrasion Laser Surgery

Other

Do you have permanent makeup/implants or injectables (Filler/Botox) in treatment area?

Yes No

Details:

Have got ANY type of skin tan (fake or natural/sun exposure)?

Yes No

Details:

How did you hear about us?

Kirby-Desai Scoring

Skin Type Analysis

How would you rate your skin in the area to be treated

Type I- Always burn, never tan. Extremely fair skin/blonde hair/blue/green eyes. Type II- Usually burn, tan less than about average. Fair skin, sandy brown to brown hair, green/blue eyes. Type III- Sometimes burns, gradually tans about average. Medium skin, brown hair, green/brown eyes. Type IV- Sometimes burns, tans light brown or olive skin, dark brown eyes and hair. Type V- Rarely burns, tans profusely. Dark brown skin, black hair, black eyes. Type VI- Deeply pigmented, never burns. Black skin, black hair, black eyes.

Colour/s of Tattoo:

Black only Most Black, some Red Most Black, some Red & other Multiple Colours

Amount of Ink:

Amateur Minimal Moderate Significant

Scarring and Tissue Change:

No Scar Minimal Scarring Moderate Scarring Significant Scarring

Tattoo Layers:

No Yes

Total Points

Test Patch- Test 1

Area

J/cm 2

Result

Notes

Test Patch- Test 2

Area

J/cm 2

Result

Notes

Test Patch- Test 3

Area

J/cm 2

Result

Notes

Client Treament Report

Date of Treatment

Clinician Name

Clinician Signature

Treatment Area

Settings Used

Amount Paid

Payment Details

Comments

Medical Informed Consent

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

In relation to my laser tattoo removal treatment, I have been advised as follows:

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 30+ 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: (Please initial)

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 consent to photographs taken to evaluate effectiveness. Photographs revealing my identity will not be used without consent. 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 am aged 18 years or over (otherwise parent or guardian to sign). I will advise (salon) of any changes that occur during my treatment that can increase potential risks or reduce efficacy. I also understand that there will be no refund for any performed services.

In relation to my initial and all subsequent treatments I advise that: (Please tick)

I have read all of the above and had all my questions satisfactorily answered. Note: Do not sign this form until you have read and understood all of the above.

Client Full Name(Please print name)

Client Signature

Date

Parent/Guardian Full Name (Please print name) *Under 18 years of age requires parental consent

Parent/Guardian Signature

Date

Pre & Post Care Information Sheet
(Client Copy)

Post Laser Tattoo Removal Treatment Recommendations

No heavy exercise, hot showers, saunas, or anything that will create excess sweat and increase body temperature for 24 hours.
Re-apply aftercare cream (Bapanthen) for the next 3 days and avoid sun exposure for 4 weeks.
Keep the area clean and clear from water after 4 hours

For any questions, concerns or booking please contact our salon on ………………………………………….…

In the event of an emergency, contact our senior clinician directly on …………………………………………… or your local doctor.

Consent Form

Schedule Your Visit Today

Laser Tattoo Removal Consultation& Consent Form

Kirby-Desai Scoring

Skin Type Analysis

Total Points

Test Patch- Test 1

Test Patch- Test 2

Test Patch- Test 3

Client Treament Report

Medical Informed Consent

Pre & Post Care Information Sheet(Client Copy)

Post Laser Tattoo Removal Treatment Recommendations

schedule A Visit

Pre & Post Care Information Sheet
(Client Copy)