"Laser Tattoo Removal Consultation and Consent Form - Images Hair and Beauty"

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Laser Tattoo Removal Consultation and Consent Form
Title ________ First Name _____________________________
Surname _____________________________________________________
Address _______________________________________________________________________________________________________________
Occupation __________________________
Email Address ____________________________________________________________
Mobile _______________________________
Home Ph _________________________________________________________________
Date of Birth __________________________
Ethnic Background ________________________________________________________
Family Doctor Name and Contact No: ___________________________________________________________________________________
Emergency Contact Name and Telephone _______________________________ Relationship ___________________________________
How did you find out about our salon? ___________________________________________________________________________________
Tattoo Information
Location of tattoo/s:____________________________________________________________________________________________________
Is the tattoo:  Professional
 Amateur
 Traumatic
 Surgical
 Other:
_______________________________________
Do you have any current or chronic medical illnesses?
 Yes
 No
Details __________________________________________
Are you currently under a doctor’s care?
 Yes
 No
Details __________________________________________
Have you taken blood thinners or anti-coagulants in last 3 mths?  Yes
 No
Details____________________________________
Have you taken photosensitising medication in last 3 mths?
 Yes  No
Details ____________________________________
(ie. Anti-depressants, St. John’s Wart, Roaccutane etc?)
Do you have (or getting treated for):  Cancer
 Heart condition
 Poor healing ability  Auto-immune disorder
Have you had (in tattoo area):  Chemical peel  Dermabrasion  Laser  Surgery  Other : _______________________
Do you have permanent makeup or implants?
 Yes
 No
Details __________________________________________
Have you got ANY type of skin tan (fake or natural)?
 Yes
 No
Details __________________________________________
Do you smoke?
 Yes
 No
If so, how many per day?
_______________________________________________
Do you have any allergies?
 Yes
 No
If so, please list ___________________________________________________
Client Name:
Client Signature:
Clinician:
Date:
________________________
__________________________
__________________________
______________
Kirby-Desai Scoring
Skin Type:
How would you rate your skin in the area to be treated?
1 
Type I
Always burn, never tan. Extremely fair skin/blonde hair/blue/green eyes
2 
Type II
Usually burn, tan less than about average. Fair skin, sandy brown to brown hair, green/blue eyes
3 
Type III
Sometimes burns, gradually tans about average. Medium skin, brown hair, green/brown eyes
4 
Type IV
Sometimes burns, tans Light brown or olive skin, dark brown eyes and hair.
5 
Type V
Rarely burns, tans profusely. Dark brown skin, black hair, black eyes
6 
Type VI
Deeply pigmented, never burns. Black skin, black hair, black eyes
Location:
1  Head and neck
2  Upper trunk
3  Lower trunk
4  Proximal extremity 5  Distal extremity
Colours:
1  Black only
2  Most black, some red
3  Most black, some red & other
4  Multiple colours
Amount of Ink:
1  Amateur
2  Minimal
3  Moderate
4  Significant
Scarring and Tissue Change:
0  No scar
2  Minimal scarring
3  Moderate scarring 4  Significant scarring
Tattoo Layers:
TOTAL POINTS __________
0 No
2 Yes
Laser Tattoo Removal Consultation and Consent Form
Title ________ First Name _____________________________
Surname _____________________________________________________
Address _______________________________________________________________________________________________________________
Occupation __________________________
Email Address ____________________________________________________________
Mobile _______________________________
Home Ph _________________________________________________________________
Date of Birth __________________________
Ethnic Background ________________________________________________________
Family Doctor Name and Contact No: ___________________________________________________________________________________
Emergency Contact Name and Telephone _______________________________ Relationship ___________________________________
How did you find out about our salon? ___________________________________________________________________________________
Tattoo Information
Location of tattoo/s:____________________________________________________________________________________________________
Is the tattoo:  Professional
 Amateur
 Traumatic
 Surgical
 Other:
_______________________________________
Do you have any current or chronic medical illnesses?
 Yes
 No
Details __________________________________________
Are you currently under a doctor’s care?
 Yes
 No
Details __________________________________________
Have you taken blood thinners or anti-coagulants in last 3 mths?  Yes
 No
Details____________________________________
Have you taken photosensitising medication in last 3 mths?
 Yes  No
Details ____________________________________
(ie. Anti-depressants, St. John’s Wart, Roaccutane etc?)
Do you have (or getting treated for):  Cancer
 Heart condition
 Poor healing ability  Auto-immune disorder
Have you had (in tattoo area):  Chemical peel  Dermabrasion  Laser  Surgery  Other : _______________________
Do you have permanent makeup or implants?
 Yes
 No
Details __________________________________________
Have you got ANY type of skin tan (fake or natural)?
 Yes
 No
Details __________________________________________
Do you smoke?
 Yes
 No
If so, how many per day?
_______________________________________________
Do you have any allergies?
 Yes
 No
If so, please list ___________________________________________________
Client Name:
Client Signature:
Clinician:
Date:
________________________
__________________________
__________________________
______________
Kirby-Desai Scoring
Skin Type:
How would you rate your skin in the area to be treated?
1 
Type I
Always burn, never tan. Extremely fair skin/blonde hair/blue/green eyes
2 
Type II
Usually burn, tan less than about average. Fair skin, sandy brown to brown hair, green/blue eyes
3 
Type III
Sometimes burns, gradually tans about average. Medium skin, brown hair, green/brown eyes
4 
Type IV
Sometimes burns, tans Light brown or olive skin, dark brown eyes and hair.
5 
Type V
Rarely burns, tans profusely. Dark brown skin, black hair, black eyes
6 
Type VI
Deeply pigmented, never burns. Black skin, black hair, black eyes
Location:
1  Head and neck
2  Upper trunk
3  Lower trunk
4  Proximal extremity 5  Distal extremity
Colours:
1  Black only
2  Most black, some red
3  Most black, some red & other
4  Multiple colours
Amount of Ink:
1  Amateur
2  Minimal
3  Moderate
4  Significant
Scarring and Tissue Change:
0  No scar
2  Minimal scarring
3  Moderate scarring 4  Significant scarring
Tattoo Layers:
TOTAL POINTS __________
0 No
2 Yes
Medical Informed Consent
I consent and authorise (Salon name) to perform laser tattoo removal treatment on me. I understand the following points and
have had the opportunity to ask questions during my consultation.
In relation to my treatment, I have been advised as follows:
1. Treatment is successful on most clients but my individual results cannot be guaranteed
2. Most clients require 8 to 10 treatments to achieve up to 80% pigmentation reduction, some may require more. Outcome will
vary and individual results depend on many factors, thus it is extremely difficult to advise on exact number of treatments
required
3. Darker skin type clients will require additional treatments
4. Exposure to UV Rays will compromise my treatment, therefore I will use SPF 30+ sunscreen
5. Home care requirements
6. Treatment process
7. Side effects
Risks associated with laser tattoo removal treatment:
Even though the risk of complication is extremely low, the following can occur: (Please Tick)
 Pigment changes (light or dark spots on the skin) lasting 1-6 months. Freckles may temporarily or permanently disappear in
treated areas. Other potential risk include crusting, itching, pain, bruising, pimple-like bumps, dry skin, hypopigmentation
(lightening of the skin), hyperpigmentation (darkening of the skin), blistering, burns, infection, scabbing, swelling, a very
small risk of scarring and a failure to achieve the desired result
 Allergic or delayed inflammatory reactions can develop. A test patch is performed to ascertain reaction of the skin
 Laser can cause eye injury and protective eyewear must be worn during treatment
 I consent to photographs taken to evaluate effectiveness. Photographs revealing my identity will not be used without consent
 I understand the laser tattoo removal treatment is uncomfortable and may be quiet painful
 I understand lighter coloured inks, such as white, yellow, orange and lighter green, will be ineffective
 I am aged 18 years or over (otherwise parent or guardian to sign)
 I will advise (salon) of any changes that occur during my treatment that can increase potential risks or reduce efficacy
 I also understand that there will be no refund for any performed services
In relation to my initial and all subsequent treatments I advise that: (Please Tick)
 I have not had unprotected sun exposure (including tanning beds and fake tan creams) in the last 4 weeks
 I have no history of seizures and I have disclosed all known allergies (e.g. Latex, etc)
 I am not taking medications causing photosensitivity (prescription/non-prescription) eg. St John’s Wort, Anti-coagulants, etc
 I do not have a history of keloid & hypertrophic scar formation
 I do not have active infections/Immunosuppression
 I do not have open lesions in the areas to be treated
 I do not have Herpes I or II – in the areas to be treated
 I have not used Tretinoin (Retin –A, Renova) within the last 2 weeks.
 I have not had Laser Resurfacing within the last 6 months
 I have not a Chemical Peel – within the last 4 weeks
 I have not used Oral isotretinoin/Accutane – within the last 6 months
 I have advised my clinician if I am diabetic
 I am not pregnant
 I have received the Pre and Post Care Information Sheet. I agree to adhere to all these recommendations
 I agree to allow Images Hair & Beauty/Global Beauty Group to use my before and after photos in marketing. This consent
does not extend to my personal details being shared in any form of media.
 Cancellations: Failure to provide 24 hours notice prior to appointment will result in loss of 1 session if sessions are pre-
purchased.
I have read all of the above and had all my questions satisfactorily answered. Note: Do not sign this form until you have read
and understood all of the above.
Name in Full ____________________________________________________________ Date ________________________________
Signature ____________________________________________________________________________________________________
Clinician (witness) ____________________________________________________________________________________________
Client Treatment Report
Date of
Clinician Name & Signature
Wavelength
J/cm
Clinician Notes
2
Treatment
Treatment Details
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