Tattoo removal consent form
Tattoo Removal/Lightening – Medical and Consent The following confidential medical information will be property of Vallyn Hair and Permanent Makeup LLC. This is required for the benefit and safety of the client in obtaining any and all procedures performed by Vallyn Hair and Permanent Makeup LLC. 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: _______________________________________________________DOB: ___________________ Age: ________ EMAIL: _____________________________________________________________________________________________ ADDRESS: __________________________________________________________________________________________ ____________________________________________________________________________________________________ PHONE : _________________________ Cell / Landline Alt Phone: _________________________ Cell / Landline Cell phone provider ________________ (So that you can receive reminder text about your appointments). How did you hear about us? ________________________________________________________________________ Would you like to be informed of any specials, discounts or events in the future? Yes /No ARE YOU CURRENTLY UNDER THE CARE OF A PHYSICIAN? Yes/ No If YES WHY? _________________________________________________________________________________________
Yes/No Please Answer The Following Questions to Avoid Complications :
YES/NO ARE YOU PREGNANT, NURSING, OR LACTATING?
YES/NO I am over the age of 18 and in sound mind, body, and health.
YES/NO DO YOU USE ASPRIN FOR BLOOD THINNING?
YES/NO DO YOU TAKE ASPRIN DAILY?
YES/NO ARE YOU REQUIRED TO TAKE ANTIBIOTICS PRIOR TO DENTAL OR MEDICAL PROCEDURES?
YES/NO HAVE YOU TAKEN ANY FORM OF MOOD ALTERING MEDICATION IN THE LAST 12 Hrs.?
YES/NO Do you have any mental impairment that may affect your judgement?
YES/NO ARE YOU ALLERGIC OR HAVE ANY SENSITIVITY TO LATEX? YES/NO Have you had a chemical peels recently?
YES/NO Do you have any Permanent makeup or tattoos?
YES/NO Have you had any complications with previous tattoos or Permanent Makeup before?
YES/NO Are you currently undergoing radiation or chemo therapy?
YES/NO Are you annemic?
YES/NO Do you bruise easily?
YES/NO Do you heal slowley or have complications with healing?
YES/NO Do you have any allergies to metal?
YES/NO Do you have any allegies to products containing “ Caine?” ie., Lidocaine etc. YES/NO
Do You have a history of skin diseases? If YES, Please Explain__________ LIST ALL MEDICATIONS BOTH PRESCRIPTION AND OVER THE COUNTER THAT YOU ARE CURRENTLY TAKING ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ Please list any Anti Inflamatory, Steriods, or Immunosuppressive Medications you currently take? ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ Please list any allergies to Petroleum based products, topical antibiotic polysporin, Bacitracin, Neosporin? ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ Medical release continue: PLEASE CIRCLE IF YOU HAVE A HISTORY OF ANY OF THE FOLLOWING CONDITIONS:
• Hepatitis • Aids or HIV • Hemophlia or • Excessive Bleeding • Hyper-pigmentation • Heart Condition • Asthma • Ocular Herpes Diabetes • Glacoma • Stroke • Angina or Chest Pains • Allergies to Makeup • Any Form of Cancer • Kidney Disease • Accutane Treatments • Auto immune Disorders • Dry Eyes • Keloid or Hyperthrophy Scars • Rheumatoid Arthritis OTHER?_____________________________________________________________________________________________ _______________________________________________ ____________________________________ SIGNATURE ______________________________________________ PRINT SIGNATURE I, currently have an unwanted tattoo. This pigment is located on ____________________(area of my body). This area was last tattooed on (date) ________________ by ______________________________________________ (name of Technician/Facility). This procedure was tattooed _________ times. This pigment is unwanted because (indicate: shape, color or location). _______________________________________ I would like my technician to attempt to: (a) remove the tattoo if possible; or (b) partially remove the tattoo or (c) lighten the tattoo. (Select One) 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 About Face Ink or it’s practitioners responsible for any resultant failure to remove, partially, totally or to lighten. I will not hold About Face Ink 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 to conform to all rules and regulations established by About Face Ink and it’s Practitioners, to ensure a successful removal/lightening of the unwanted pigment/tattoo. I agree to follow all aftercare instructions. I have been informed of the nature, risks, possible complications and consequences as listed above. I further understand that About Face Ink 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 (print name) ______________________________________________________, 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 About Face Ink 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 About Face Ink and it’s Practitioners from any liability. About Face Ink’s 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. ____________________________________________________________________ ___________________________________ Clients Signature Date I have reviewed the information with my client or clients representitive ____________________________________________________________________ __________________________________