LASER TATTOO REMOVAL
CONSENT FORM
Please complete the consent form below.
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Select Studio
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Select Studio
West Bromwich
Name of Client
Client Address
Contact No.
Email Address
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Date of Birth
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Form of ID Used
*
Form of ID Used
Passport
Driving Licence
Other
Medical Background: Check all that apply (past and present)
Skin Conditions
Heart / Kidney / Liver Disorders
High / Low Blood Pressure
Haemophilia / Bleeding Disorders
Epilepsy
Diabetes
Autoimmune Disease
Cancer
HIV
Pregnant
Breast Feeding
Cardiac Problems
Current Medication
Other Medical Conditions
Allergies
Individual Consent
*
I Agree
I agree that I am over the age of 18, am NOT under the influence of alcohol or drugs, and am mentally capable of contracting in my name.
I understand that the possible side effects of laser tattoo removal include but are not limited to pain, bruising, swelling, redness, blistering, permanent scarring, hypopigmentation, hyperpigmentation, infection, bleeding, residual tattoo pigment or visible tattoo pattern remaining. I understand that patients with darker skin tones have an increased risk of complications occurring from receiving laser tattoo removals such as hypopigmentation, hyperpigmentation, burns, and scarring.
I elect to receive this procedure from "New Identity Tattoo Studio" knowing all of the benefits, risks, contraindications, and potential complications.
I have been informed of the nature, risks and possible complications of the laser tattoo removal procedure. I have fully disclosed all health factors to my therapist to avoid any complications. I understand that results may vary per client and there are no guarantees as to the results of this treatment.
I understand this agreement is binding and that I have read and fully understand all information listed above. I represent that I am over the age of 18.
I have completed this form to the best of my ability and knowledge and agree to inquire about questions I may have before "New Identity Tattoo Studio" begins performing the procedure.
I have been informed of and understand the contraindications to the requested treatments and agree that I do not have any condition(s) that would make the requested treatment unsuitable.
I will inform my esthetician of any discomfort I may experience during the requested treatment to allow them to adjust accordingly.
I agree to waive all liabilities toward my esthetician and "New Identity Tattoo Studio" for any injury or damages incurred due to any misrepresentation of my health.
Name of Client
Today's Date
*
Client Signature
*
Clear Signature
Practitioner Name
Practitioner Signature
*
Clear Signature
Message
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