Laser Removal Consultation Form.This salon will not perform any tattoo removal procedure on anyone under the age of 18 or under the influence of alcohol or illegal drugs.Please filling the following information prior to your appointment. Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Phone (###) ### #### Ethnicity * Please describe your ethnic origin. Area(s) of body to be treated * Please describe the area of your body that you would like to be treated. Emergency contact * Please list your emergency contact & phone number Tanning * Please inform your technician if you have an active SUNTAN (been in the sun in the last 6 weeks, even if not deliberately ‘tanning’) as a failure to declare this could lead to a burn to the skin during treatment. Tanned skin cannot be treated! Disclaimer * I understand that the efficacy of tattoo removal varies between individuals and that every patient heals differently. A small percentage of people will not respond satisfactorily to treatment. I understand that this is an elective procedure that is not medically necessary. It is a multi treatment process which isn’t considered complete after the initial treatment, it will require a number of treatments to achieve the desired results. I accept that after the treatment the direct area treated may show signs of swelling, redness, pinprick bleeding, bruising and in some cases blistering/ mild burns. There is also a risk of hypo-pigmentation (lightening of the skin) or hyper-pigmentation (darkening of the skin) as well as a rare side effect of permanent discolouration or scarring. I accept that I also may experience some discomfort during and after treatment. I accept that my tattoo will continue to lighten between treatments as my body’s immune system continues to remove broken down pigment molecules. This has been explained to me. I understand that I must avoid sun exposure on the treated area for the duration of the treatments (and for up to 1 month afterwards) I must keep it completely covered from sun exposure for 2 weeks either side of an appointment, and then wear an SPF 50 over it at all other times. I confirm I will strictly adhere to the aftercare instructions given to me. Should I get an infection post treatment I will visit my GP and I accept that this is because I do not live in sterile conditions. I will also let the clinic know, and contact them to discuss any concerns. I understand I will be provided with safety goggles to wear during my treatment to prevent damage from the light. I hereby give my written consent for Laser treatments for the purpose of removing my tattoo(s). I have read and fully understand all the points listed in this procedure consent form. I accept full responsibility for any complications that may arise during or following the treatment. Important Due to the increased usage of white (camouflage/highlighter) ink in tattoos, we are making our clients aware of the impact that this can or may have on LASER tattoo removal. The white ink can contain zinc oxide or titanium oxide which when treated with a LASER could oxidise and turn grey, yellow or black. If this happens it may increase the amount of treatments or in some cases not remove at all. Our clients are important to us which is why we feel it’s important that you know this information so as to aid you in your decision for LASER tattoo removal. Signature * Please include your first and last name here to sign. First Name Last Name Date * Please add today's date MM DD YYYY MEDICAL INFORMATION AND MEDICATION * Are you currently undergoing any medical investigations by a doctor or hospital specialist? Yes No If 'yes' please give details Please list any medication you are currently taking: Have you ever had Laser tattoo removal before? * Please select Yes or No Yes No If 'Yes' please give details Please indicate any that apply to you: * Please select any that apply to you: Pregnant or Planning Suntanned/using sunbeams / fake tan Skin pigmentation disorder (e.g Melasma, Vitiligo History of cancer (or chemo/radio therapy) Diabetes Epliepsy Lymphatic/immune system disorder Lupus Communicable diseases (Hepatitis/HIV) Photosensitive conditions Depression/Anxiety High blood pressure Anaemia History of keloid formation/scarring Haemophilia Regular smoker Regular drinker Any other Allergies Are you currently using or have used in the last 6 months, any of the following? Please select all that apply St John’s Wort Anti coagulants Oral or Topical retinoids (e.g Roaccutane or Retin A) Amoiderone Gold medications Oral or topical steroids Minocycline Are you currently recovering from any major medical treatment or photodynamic therapy (PDT) within the last 6 months? Please select yes or no. Yes No Has the area for treatment ever had any of the following? Please select all that apply Moles Birthmarks Permanent make up Chemical Peel Botox Injectable fillers Tanning injections or enhancers Melanotan Do you have any allergies to latex? * Please select Yes or No Yes No Have you ever suffered from any skin disorders or disease? * Please select Yes or No Yes No If yes please specify the condition and any medications Please indicate how your skin responds to midday summer sun exposure with NO sunscreen * Please select all that apply Skin type 1: Always burns, never tans Skin type 2: Easily burnt, eventually gets a moderate tan Skin type 3: Sometimes burns, quickly gets an average tan Skin type 4: Rarely burns, quickly gets a deep tan Skin type 5: Very rarely burns, consistent tan Skin type 6: Never burns, consistent tan Do you currently have a real or fake tan? * Please select Yes or No Yes No Have you had any sun exposure or used a sun bed in the last 4 weeks? * Please select Yes or No Yes No What are your goals for treatment? * Complete removal Fading for a cover up Where did you hear about the clinic? * Recommendation Social media Leaflet Press Other Privacy Statement * Here at Vy Brows Artistry, we take your privacy seriously and will only use your personal information to administer your account and to provide the treatments and services you have requested from us. Any personal and medical information you provide will only be used by our technicians in connection with your treatment and stored in a locked cabinet within the clinic at all times. The correct personal and medical information is necessary to carry out your treatment safely. If at any point you believe the information we hold is incorrect you may request to see this information and have it corrected or deleted. Your information will never be passed on to any third party apart from our online appointment diary. This will send you reminders and confirmations of your appointments via message. By Law and for insurance purposes your basic personal data i.e name, date of birth, address, medical details are required to be kept for a minimum of 5 years, after which it will be securely destroyed. Please indicate that you consent to receive appointment reminders and confirmations by text and for us to securely store your personal and medical information Yes No Photographic/Video Release Form * I give my consent for any photographs or videos taken of my procedure at Vy Brows Aristry to be used on social media sites/websites for the purpose of advertising. Yes No Thank you!