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

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

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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