Client Name *

First Name

Last Name

Mobile Number *

(###)

###

####

Area of Cosmetic Tattoo *

Eyebrow Tattoo

Eyeliner Tattoo

Lip Tattoo

Freckle Tattoo

Scalp Tattoo

Other

Have you had tattoo removal done before on the area? *

No

Yes

Desired Result: *

Removal - Never Want Another Tattoo

Removal - I Want Them Redone

Colour Correction - Help They Are Red or Grey or Too Dark

Where was tattoo was made? *

Australia

Overseas

What is the current colour of the tattoo?

Bluish Black

Black

Dary Grey

Ash Brown

Warm Brown

Blonde

Red

Purple

Orange

Green

Were any corrective camouflage inks (skin colour) used ? *

No

Yes

Contraindications *Laser Only ^Doctor note may be required

*Anti-Inflammatory Drugs

Antibiotics

Auto Immune Disease

Bleeding Disorders / Haemophilia

Botox/ Filler (local)

^Chemotherapy / Radiotherapy

Cold Sores / Herpes Simplex

^Diabetes

^Epilepsy

**Eye Injury or Condition

Fever / General Illness

High Blood Pressure

*Hyper / Hypo Pigmentation

Keloid Scarring

*Metal Implant (near the area)

*Pacemaker

*Photo Dermatosis

*Photo Sensitive Drugs

Pregnant or Breast Feeding

Ro-Accutane or siliar

^Skin Cancer / Terminal Cancer

Skin Conditions

Skin Pigmentation/ Birth Marks ect

*Smoking

Steroid or Cortisone Creams

Sunburn

*Tanning Products

Topical Vitamin Creams

Warfarin or Anti-Coagulants

Multiple sessions will be necessary to achieve desired results. I understand results may vary from person to person and that complete tattoo removal is not always possible. I understand that the provided method for removing tattoo pigment/ink that results can vary according to the ink used, age of tattoo, area on the body that tattoo is situated, how the tattoo was created, general health, lifestyle, skin type as well as the medical condition of the client. No guarantee, warranty or assurance has been made to me as to the results that may be obtained. *

I AGREE

I am over the age of 18 *

I AGREE

Possible side effects of the treated area include but not limited to mild temporary discomfort, redness or swelling, Pinpoint bleeding, blistering, crusting, bruising and wound infection may occur. *

I AGREE

Rare side effects include the possibility of a paradoxical darking of the tattoo ink/pigments. This has been observed with treatments of pastel colours and on permanent make-up colours. Scarring is uncommon but it is a risk. *

I AGREE

Textural and/or colour changes in the skin may develop. Colour changes, such as hyperpigmentation (brown/red discolouration) or hypopigmentation (skin lightening) may occur in treated skin. This may take many months or more to return to normal. Skin must be protected from the sun for six weeks before and after treatment. Unprotected sun exposure in the weeks pre and post treatment may produce hyper/hypo pigmentation. *

I AGREE

Some medications and suntans prohibit the laser tattoo removal process. Persons on Accutane and photosensitizing medications cannot be treated and if you have suntanned within the last 6 weeks or have a spray/synthetic tan you cannot be treated. *

I AGREE

Infection following laser tattoo removal is unusual however, bacterial, fungal and viral infections can occur. Should any type of skin infection occur, I will immediately seek medical advice. *

I AGREE

Compliance with aftercare guidelines is crucial for healing, prevention of scarring, infection and hyper- pigmentation. I have received written aftercare information and agree to follow aftercare recommendation as directed by this clinic. *

I AGREE

I hereby release the technician and associates from any and all claims; which I have now or in the future arise from the tattoo process. I will not hold the technician responsible in the event of any damages and shall not be entitled to take action against him/her at Law or in Equity for such treatment. *

I AGREE

I understand photos/video are necessary to document the treatment process . From time to time we may use these to educate students or promotional purposes.

I AGREE

How did you hear about us?

Instagram

Facebook

Google

Word of mouth

Other

Technician has evaluated your form and answered ALL questions *

Yes

No

Fitzpatrick

1

2

3

4

5

6

Spot Size

5

6

7

8

9

10

Colour Behaviour

Sunset Warm

Sunset Cool

Carbon Resistance

Paradoxical Darkening

Pigment Relapse

Pigment Regression

Pigment Plateau

Other

Adverse Reaction

Blistering

Bruising

Frosting

Inflammation