Laser Tattoo Removal Consultation/Consent Form | Aesthetics Forms Portal

Laser Tattoo Removal Consultation and Consent Form

Client Details

Name: *

Contact Number: *

Email: *

Date of Birth: *

Medical History

Are you currently taking any medication? *

Please list: *

Do you have any allergies or intolerances? *

Please list: *

Are you currently (or is there a possibility you may be) pregnant or breastfeeding? *

Do any of the following apply to you? Please tick all that apply.

Do you have any other medical conditions? *

Please list: *

Have you recently been unwell? *

Which of the following have you been unwell with? *

Please provide more detail: *

Emergency Contact Details

Emergency Contact Name: *

Emergency Contact Relationship: *

Emergency Contact Phone: *

Consultation

Please upload a clear image of the tattoo to be removed: *

When did you get the tattoo? *

Where on your body is your tattoo located? *

Do you have scarring on or around your tattoo? *

Has the tattoo previously been covered up? *

Please specify how many tattoo layers you have: *

Fitzpatrick skin types:

1) Very pale white skin, often with green or blue eyes and fair or red hair - burns without tanning

2) White skin, often with blue eyes - burns and does not tan easily

3) Fair skin with brown eyes and brown hair - burns first then tans

4) Light brown skin, dark eyes, and dark hair - burns a little and tans easily

5) Brown skin, dark eyes, and dark hair - easily tans to a darker color and rarely burns

6) Dark brown or black skin, dark eyes, and dark hair - never burns but tans darker

Which of the above skin types best describes your skin? *

Tanning History (Direct sun, Self-tanners, Spray tans etc.). Please list and include last date of use: *

Have you previously had any laser treatment? *

Tattoo Removal, Skin Resurfacing, Hair Removal etc.

Previous Laser Treatment(s) - If known, please specify date, number of treatments, frequency, response to treatment, device used: *

Do you use sunscreen? *

Do you smoke? *

Treatment Information

You'll need to shave the area of skin before your appointment.

On the day, you'll be given special goggles to protect your eyes. A local anaesthetic cream may be used to numb the skin.

A handheld device will be pressed on your skin to trigger a laser. Some people say this feels like an elastic band snapping against your skin.

The session will take about 10 to 30 minutes, depending on the size of your tattoo.

The tattoo should become lighter with each treatment.

A gel is used to cool and soothe your skin, and it might be covered with a dressing.

Potential Side Effects and Risks

Limitations

Tattoo removal has some limitations including:

It can be uncomfortable
It's a very slow process – 10 or more sessions may be needed to remove the tattoo
Many tattoos cannot be completely removed – It's quite common to have some ink left in the skin
Some colors do not fade as well as others

You should not have a tattoo removed if you:

Are pregnant – There's a small risk to your baby
Have a suntan or false tan – Wait for it to fade

Risks

Possible risks are:

Some colors not completely fading – Yellow, green and purple ink requires more sessions to fade than black, blue and red
A small chance your skin may become temporarily darker or paler than the surrounding skin
A slight chance of permanent scarring (3 in 100 people develop a scar)

Aftercare Advice

Your skin may be red with a raised rash for a short while after treatment. Holding an ice pack to your skin may help.
You may have some slight bleeding before your skin scabs over. Use aloe vera gel or Vaseline to help it heal.
Your skin will be more sensitive to the sun. Avoid sun exposure and tanning beds for at least 1 week after a treatment. Cover the area with clothing and use a sunscreen with at least SPF30.
You should avoid:
- picking or scratching the scab
- using soap or perfumed products on the area for the first 48 hours
- strenuous physical activities for a couple of days
- swimming and saunas until the scab has dropped off (they may slow the healing process)

Please tick the box to confirm: *

I have read and understood the aftercare advice given to me on this form.

Consent

I accept that any treatment I am going to receive is at my own risk.

I certify that I have read, fully understood, and completed this form to the best of my knowledge.

I understand that failure to disclose information requested above may result in adverse side effect(s), unknown because of this to which I accept full liability/responsibility.

The treatment(s) and possible side effect(s) have been fully explained to me.

I accept full responsibility for the treatment given and complications which may arise or result during or following any procedure that is performed at my request.

I accept that if I am not satisfied with the treatment I will inform the therapist and/or request to speak to the manager during, or immediately following, the treatment.

I fully understand the above and consent to the Laser Tattoo Removal treatment(s) to be carried out.

Client Signature: *

Tap or click on the signature above to sign