Saline Removal Consultation and Consent Form

Client Details

Full Name: *

Date of Birth: *

Contact Number: *

Email: *

Medical History

1. Are you currently taking any medications? (Oral or Topical) *

Please specify: *

2. Do you have any allergies? *

Please specify: *

3. Are you currently taking any blood thinning or anticoagulant medication (i.e. aspirin etc.)? *

4. Do you have any cutaneous (skin) infection or inflammatory problems (e.g. herpes/cold-sores, acne etc.)? *

5. Have you ever suffered from an auto-immune disease or any condition affecting the immune system? *

6. Have you had any complications with previous tattoos or Permanent Makeup before? *

Please specify: *

7. Do you heal slowly or have complications with healing? *

8. Do you have any other medical conditions? *

Please specify: *

9. Have you recently been unwell? *

Which of the following were you unwell with? *

Please provide detail: *

Emergency Contact Details

Emergency Contact Name: *

Emergency Contact Relationship: *

Emergency Contact Phone: *

Treatment Details

How does the treatment work?

The procedure in which salt and saline paste is used is similar to micro-pigmentation. The difference is we are going to introduce salt into the upper dermis rather than pigment. The removal formula starts to act as soon as it is applied to the original tattoo. The scab will form over the tattooed area. In the next few days while the skin heals, the ink will be drawn out from the tissue that regenerates into the patchy part of the scab. The scab will start naturally to peel and consequently the undesired ink will be extracted from the skin. After the procedure, the area where the scab has formed should be kept completely dry/no water.

General Information & Risks

Salt Paste treatment has been proven to be a safe and effective treatment for tattoo removal. Alternative treatments exist that include laser, dry needling, acid solutions and surgical removal with skin grafting. All of these come with respective inherent risks.

The risks with Salt Paste treatment include:

Potential for scarring
Bleeding
Infection
Lightening or darkening of the skin's natural pigment
Hair loss and inability for the affected area to tan.
In some cases, the therapy may fail to remove all pigment.

Consultation

Describe the tattoo to be lightened and the area it is located: *

When was the area last tattooed? *

I would like my technician to attempt to: *

Remove the tattoo if possible Partially remove the tattoo Lighten the tattoo

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 would you say is closest to your skin? *

Consent

I understand that lightening tattoo pigment is difficult and as a result I will not hold my technician responsible for any failure to lighten the unwanted pigment.
I agree to follow all aftercare instructions instructed by my technician.
The nature and method of the proposed pigment (tattoo) lightening procedure has been explained to me, including risks or possibility of complications during or following its performance. I understand there may be a certain amount of discomfort or pain associated with the procedure and that the other adverse side effects may include: minor and temporary bleeding, bruising, redness or other discoloration and swelling. Secondary infection in the area of the procedure may occur, however if properly cared for, this is rare.
I understand that several treatments may be needed in order to attempt to achieve my desired results depending on the darkness and depth of the ink of the tattoo. However, the outcome of the procedure cannot be guaranteed as all skin types differ and heal differently.
I understand that the unwanted pigment may not be successfully lightened to the point that it can no longer be seen. Scarring, hyperpigmentation or hypopigmentation, or other damage to the skin may occur during this process and may be permanent. This is rare but it can happen. I will not hold my technician, the studio and/or the distributor/manufacturer of tattoo removal products used in this attempted pigment (tattoo) lightening or removal liable for any damages that may occur to my person.

Please read each statement carefully and tick to show your agreement. *

I accept that any treatment I am going to receive is at my own risk. I certify that I have read and 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) and therefore I accept full liability/responsibility for the information given. 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 practitioner and/or request to speak to the manager during or immediately following the treatment. I fully understand the above and consent to receive a Saline Removal treatment.

Client Name, Signature and Date: *

Tap or click on the signature above to sign