Private and Confidential – recorded only for the purposes of a cosmetic tattoo removal treatment.
To order your numbing cream please refer to SMPU before page.
CONSENT FOR COSMETIC TATTOO (PMU) PIGMENT LIGHTENING AND/OR REMOVAL
Date ________ Name (Please Print) DOB _________ Technician Name Company (if applicable)
Describe the cosmetic tattoo to be lightened Has the tattoo previously been treated for correction, lightening or removal? YES NO
If YES, please describe as best you can what has been done previously _______________________________ _________________________________________________________________________________________
(Examples include colour correction, liquid based removal treatment or laser removal. These are not contraindications but will help the technician understand the procedure requirements).
Allergies related to the removal liquid:
Are you allergic or have had a skin reaction to glycolic acid? YES NO
Are you allergic or have you had a skin reaction to ethyl alcohol? YES NO
Are you allergic or have you had a skin reaction to aloe vera? YES NO
Outline of procedure and acknowledgement of risks involved:
The nature and method of the proposed pigment (tattoo) lightening procedure involves introducing a liquid removal product into the skin using a cosmetic tattooing device. The philosophy is that the pigment comes out the same way it went in. There are many factors affecting how successful the procedure may be and the number of treatments that may be required to achieve the desired result. Complete removal is rarely necessary and can be difficult to achieve.
The combined actions of the cosmetic tattoo device and the liquid removal product dislodge and dissolve pigment. Factors such as pigment age, type, depth of placement, skin type and skin integrity will all influence the ease of pigment removal and number of treatments required.
There are risks and possible complications during or following the procedure. You acknowledge that there may be a certain amount of discomfort or pain associated with the procedure. Other adverse side effects may include minor and temporary bleeding, bruising, redness or other discoloration and swelling. Cold sores may occur on the lips following lip procedures in individuals prone to this problem. Secondary infection in the procedure area may occur, however if properly cared for, this is rare.
I understand the nature of the procedure and the potential risks and complications. (Client Initials)
I understand that several treatments may be required to try and achieve my desired results. I have not received any guarantees on the of the outcome of the process. (Client Initials)
I understand there are medical and other options available for cosmetic tattoo pigment removal. I have decided to decline those methods._______________________________________________(Client Initials)
I understand that the pigment may not be successfully lightened to the point that it can no longer be seen. Scarring, hyperpigmentation or hypopigmentation, discoloration 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 or the COMPANY responsible for any such consequences______________________________ (Client Initials)
I understand there will be no refunds if the desired lightening result is notachieved. (Client Initials)
Skin Type (Fitzpatrick Scale)
Which of the following best describes your skin type? (Please tick the relevant box)
I. White, always burns, never tans
II. Beige, always burns, sometimes tans
III. Light brown, sometimes burns, always tans
IV. Medium brown, rarely burns, always tans
V. Dark brown, always tans, rarely burns
VI. Black, never burns
With skin types V and VI the technician may advise against treatment or decline to treat based on the risks. If it is agreed to proceed, I understand that I am at a high risk for hyperpigmentation or hypopigmentation to occur due to my skin type. I agree to the risk involved. (Client Initials)
If you have any concerns regarding this treatment and your medical conditions or current medications, while
the technician may be able to identify possible contraindications, you are required to seek proper medical advice from a qualified professional before allowing the treatment to proceed. I acknowledge I have
read and understood this clause. (Client Initials)
Photography and Aftercare
I agree to allow before and after photographs for my client records and to monitor the treatment progress. I give my permission for such photographsto be used anonymously for publication and/or teaching purposes. (Client Initials)
I agree to follow all aftercare instructions provided by me by thetechnician. (Client Initials)
Privacy and Confidentiality
I acknowledge that when providing the information in this form I consent to the use of this information for provision of services by the Technician and the COMPANY. I consent to the uploading of my personal information to a data storage system. The information in this form and associated with the treatment will be held in accordance with the Australian Privacy Principles.
Acknowledgement
I have been duly informed of the natures, risks, possible complications,and consequences for the procedure, including the potential need for multiple treatments, if applicable. I further understand that my technician is not a medical doctor or other healthcare professional and is not providing medical advice, for which I would need to consult with a medical professional (Client initials)
I have disclosed all that has been asked of me to the best of my ability and I understand all the details and information listed above. I agree to all conditions and provisions of this document as evidenced by my signature below. I accept the risks for having this procedure done therefore release my technician and the Company from all liability. (Client Initials)
Date:________________ Signature of Client
Date: Witness
Private and Confidential – recorded only for the purposes of a cosmetic tattoo removal treatment.