Tattoo removal form

Tattoo & pigment removal form

Date(Required)

First Name(Required)

Last Name(Required)

Date of Birth(Required)

Phone(Required)

Email Address(Required)

Your Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Occupation

How did you hear about us?(Required)

Would you like to be informed of our specials?(Required)

(Please ensure you have clearly supplied your email id & contact no. above)

Yes

Ethnic Background(Required)

Family Doctor Name and Contact No(Required)

Emergency Contact Name and Telephone(Required)

Relationship(Required)

How did you find out about our salon?(Required)

Tattoo Information

Location of pigment or tattoo/s(Required)

Is the tattoo or pigment(Required)

Professional

Amateur

Traumatic

Surgical

Other

Pigmentation

sun damage

Write down the other

Do you have any current or chronic medical illnesses?(Required)

Yes

Details (If yes)

Are you currently under a doctor’s care?(Required)

Yes

Details (If yes)

Have you taken blood thinners or anti-coagulants in last 3 months?(Required)

Yes

Details (If yes)

Have you taken photosensitising medication in last 3 months?(Required)

Yes

Details (If yes)

(ie. Anti-depressants, St. John’s Wart, Roaccutane etc?)

Do you have (or getting treated for):(Required)

Cancer

Heart condition

Poor healing ability

Auto-immune disorder

None

Have you had (in tattoo area):(Required)

Chemical peel

Dermabrasion

Laser

Surgery

Other

None

Do you have permanent makeup or implants?(Required)

Yes

Details (If yes)

Have you got ANY type of skin tan (fake or natural)?(Required)

Yes

Details (If yes)

Do you smoke?(Required)

Yes

If so, how many per day?

Do you have any allergies?(Required)

Yes

If so, please list

Client Signature:(Required)

Medical Informed Consent(Required)

I consent and authorise 1st Lady Health & Beauty to perform laser tattoo removal treatment on me. I understand the following points and have had the opportunity to ask questions during my consultation.

In relation to my treatment, I have been advised as follows:(Required)

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

1. Treatment is successful on most clients, but my individual results cannot be guaranteed
2. Most clients require 8 to 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
3. Darker skin type clients will require additional treatments
4. Exposure to UV Rays will compromise my treatment, therefore I will use SPF 30+ sunscreen
5. Home care requirements
6. Treatment process
7. Side effects

Risks associated with laser tattoo removal treatment:

Even though the risk of complication is extremely low, the following can occur: (Please Tick)(Required)

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 include 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 1st Lady Health & Beauty 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)(Required)

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

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

Signature(Required)

Therapist Column (Kirby-Desai Scoring)

Skin Type: How would you rate your skin in the area to be treated?(Required)

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

Location of pigmenta or tattoo(Required)

Colours:(Required)

Black only

Most black, some red

Most black, some red & other

Multiple colours

Amount of Ink:(Required)

Amateur

Minimal

Moderate

Significant

Scarring and Tissue Change:(Required)

No scar

Minimal scarring

Moderate scarring

Significant scarring

Additional Notes:

Client Treatment Report(Required)

Date of treatment

Treatment Details

Wavelength

J/cm2

Clinician Notes

Clinician:(Required)

Everton Park +61 459 627 100 & Aspley +61 481 332 100

Tattoo & pigment removal form

Tattoo Information

Risks associated with laser tattoo removal treatment:

Therapist Column (Kirby-Desai Scoring)

Get In Touch With Us

We are waiting in our studio

1st Lady Health & Beauty

Opening Hours

Everton Park +61 459 627 100 & Aspley +61 481 332 100

Tattoo removal form

Tattoo & pigment removal form

Tattoo Information

Risks associated with laser tattoo removal treatment:

Therapist Column (Kirby-Desai Scoring)

Get In Touch With Us

We are waiting in our studio

1st ​Lady Health & Beauty

Opening Hours

1st Lady Health & Beauty