Tattoo Removal – Comprehensive Consent and Concern Form

Client Information

Full Name *

Date of birth *

Gender *

Address

Street Address

City

Postal code

Phone Number *

Email Address *

Emergency Contact Name *

Emergency Contact Phone *

Medical History

Are you currently under medical supervision or taking medications? *

Yes

No

If yes, please provide details:

Are you currently taking any medications? ( List names of the ones who apply):

Antibiotics
Hormones
Accutane
Retinoids
Blood thinners
Steroids

Have you had recent cosmetic treatments in the area targeted? *

Yes

No

Have you have any allergie ? *

Yes

No

If yes, please let us know details:

Skin Type (Fitzpatrick I-VI):

Recent sun exposure/tanning in the last 4 weeks? *

Yes

No

If yes, date of last exposure

Risks, Side Effects, and Acknowledgements

Please read and initial each statement regarding the Tattoo Removal: *

I acknowledge multiple sessions are required.

I understand side effects can include redness, pigmentation change, etc.

I will notify the clinic of any adverse reactions.

I agree to pre/post care instructions.

I confirm no Accutane use in last 6 months.

I consent to before/after photos for documentation.

Client Declaration and Consent

I confirm I have read and understood the information provided.

I have had the opportunity to ask questions.

All questions were answered to my
I understand that the clinic does not guarantee complete ink removal - (dependent on how long ago the tattoo was done & also the depth and quality of ink used).

By signing below, I confirm that I have read and understood the information provided and consent to proceed with the treatment.

Client Signature: *

Clear

Date: *

Practitioner Name (Print): *

Practitioner Signature: *

Clear

Deposit & Risk Acknowledgment Policy

Non-Refundable Deposit

I understand and agree that any deposit made for medical consultations, procedures, or treatments is non-refundable under all circumstances. This applies regardless of cancellation, rescheduling, or change of decision on my part.

Assumption of Risk

I acknowledge that all medical treatments, procedures, or interventions carry inherent risks. I have been informed of the potential benefits, risks, and alternatives related to my care, and I have had the opportunity to ask questions. I voluntarily assume full responsibility for any and all risks, outcomes, or complications that may arise from the medical care I receive. I release the provider and facility from liability for outcomes that are not guaranteed and may vary from patient to patient
24-Hour Cancellation Policy:

We require a minimum of 24 hours' notice for any appointment cancellations or rescheduling. Failure to provide at least 24 hours' notice, or missing your scheduled appointment, will result in the forfeiture and deduction of that session from your pre-paid package.

Confirmation of Understanding

By signing below, I confirm that:

- I have read and fully understood this policy

- I understand the deposit is non-refundable.

- I accept and assume all risks related to my treatment.

- I sign this document voluntarily and without coercion.

Patient Name

Patient Signature:

Clear

Date: *

I agree to terms & conditions provided by the company.

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