Tattoo Removal Personal History

Personal History For Tattoo Removal Treatments

Title

Name(Required)

Sex

Male

Female

Date of Birth

Address

Suburb

Post Code

Email(Required)

Phone(Required)

State(Required)

NSW Clinics(Required)

ACT Clinics(Required)

Would you like to receive marketing materials for promos or sales?

Emails

SMS

How did you hear about us

Google

Social Media

Flyers

Referral

Walk by

Voucher

Event

Referred By

Type of Advertisement

To determine your skin type, please tick one of the following

I – White ( Always burns, never tans )

II – White ( Mainly burns, sometimes tans )

III – White / Asian ( Sometimes mild burns, average tan )

IV – Moderate Brown ( Rarely burns, tans with ease )

V – Dark Brown ( Very rarely burns, tans very easily )

VI – Black ( Never burns )

About your health

(If answered yes to any questions, please explain)

Have you had recent sun exposure in the area, Solarium or Fake tan in the last 4 weeks?

Recent surgery or injury in the last 6 months?

Do you suffer from Auto Immune disorders?

Have you used Retin A in the last 2 weeks?

Have you used Roaccutane in the 6 months?

Do you suffer from Eczema, Dermatitis or Psoriasis?

Have you Vitiligo or other pigmented skin disorders?

Have you a Pace Maker, metal implants or heart problems?

Have you had recent cosmetic injections? (Last 8 weeks)

Have you recently had Chemical Peels or resurfacing treatments?

Are you pregnant or trying to conceive?

Are you currently breastfeeding?

Do you have a family history of Melanomas?

About your Tattoo

Where on your body is the tattoo located?

Approx. size of the tattoo?

Colour/s of the tattoo?

How old is the tattoo?

Have you had previous tattoo removal treatment?

Number of treatment?

Type of Laser Used?

Name of clinic?

Date of last treatment?

What results?

Good

Average

Poor

Please give details of any complications or adverse reactions if present.

Consent Form For Tattoo Removal Treatments

I have been advised of the following

All information regarding my treatments at Eden Laser Clinics has been provided both verbally and in writing. This includes, but is not limited to, my treatment plan, pre and post treatment care and potential adverse reactions, with all of my questions being satisfactorily answered.

I am aware I must inform the clinic if anything changes in regards to the information provided at this consultation.

I understand that there is no guarantee of full clearance of my tattoo due to various reasons outlined in the consultation, and I will follow the recommended treatment plan to ensure the best possible results are achieved.

I understand that any current/previous scar tissue will remain after treatment. Laser Tattoo Removal will not remove, improve or treat any existing scars or scar tissue.

While every precaution has been taken to prevent side effects they can and sometimes do occur. They may include temporary discomfort, temporary redness and swelling, colour changes such as hyper & hypo pigmentation

If skin lightening (hypo pigmentation ) or darkening (hyper pigmentation) occurs, it may take several months to resolve and in some cases may be permanent

Temporary crusting, bruising, mild burning sensation and blistering may occur. Infection and scarring is a rare possibility and occurs in a small % of the population

I must not expose my skin to any form of tanning during treatment and prior to any treatment, this includes sun exposure and solariums. Spray tan must be completely removed prior to treatment but may be used in-between treatments

I must advise the clinic of any sun exposure I have had as it increases the risk of any possible side effects and the risk of hyper / hypo pigmentation

I must wear eye protection as instructed by the operator

I have read and received a copy of the Client Information sheet , after care instructions and a copy of this Consent Form

I consent to photographic documentation of treatment. Photographs will not be used for advertising without my consent.

I understand that the PicoWay is a device used for removal of Tattoos which I am consenting to be receiving.

I accept all risks of treatment and consent to undergoing treatment

I understand the fee structure and the cost of undergoing the treatment.

I accept that my pre-paid treatments are not transferable or refundable

I acknowledge that I have been recommended by the therapist to use Eden Laser Clinics’ Soothing Gel, post Tattoo Laser removal treatment and that the Eden Skin Products have been specifically formulated for optimum results.

I understand that using other products purchased elsewhere may not offer the same result and/or potentially irritate the treated area

In relation to my initial and all subsequent treatments I advise that

I am not tanned from any source, including sun exposure, tanning lotions, spray tan solariums etc.
I do not have a history of abnormal scarring
I have not taken the drug Roaccutane in the last 6 months
I have not had any deep chemical peels or laser resurfacing in the last 6 months
I am aged 18 years or over (otherwise guardian to sign)
I am not pregnant

Eden Laser Clinics have a 24 hour cancellation policy. If cancellation occurs less than 24 hours or the client does not show up for their prepaid appointment, this session will be forfeited. If this treatment is PAYG, the client is required to pay a 50% deposit for their next booking.

Please do not sign this form until you have read and understand the contents. If you have any questions or concerns, please ask your therapist.

By signing below, you acknowledge you have read, understood and accept the terms and conditions outlined in Eden Laser Clinics treatment consent form, and all information you have supplied is true at the time of signing this form. If any of your medical or personal circumstances change, you must notify the clinic you attend immediately so we can update your file for future treatments.

Client name:(Required)

Client signature:(Required)