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Reversal Consent Form

Refined Removal Consent Form

CONSENT AND RELEASE AGREEMENT FOR PERMANENT COSMETIC TATTOO REMOVAL

This form is designed to give information needed to make an informed choice of whether to undergo a chemical tattoo removal procedure. If you have any additional questions, please don’t hesitate to ask!

Tattooing and permanent make up are both based on similar process of inserting pigment into the dermal layer of the skin. Inks for dermal pigmentation are composed of pigments that are suspended in a carrier solution. The tattoo pigments range from inorganic materials to azo dyes, with variable absorption spectra.

The method is not claimed to be an alternative for laser removal it is claimed as a complimentary procedure that can as well be alternated with laser sessions. Although tattoo removal has been proven effective in many cases no guarantee can be made that a specific client will benefit from the procedure.

The application of suspension based on mineral oxides is summoned to disintegrate the layer of pigment engulfing fibrosis and basement epidermal membrane subsequently breaking down pigment particles. Further scab formation and sloughing allows the trans epidermal elimination of pigment and onsets the elevation of residual pigment due to promoted cellular activity during re-epithelization and restructuring of collagen matrix.

BEFORE AND AFTER THE TREATMENT

Removal is a procedure that consists of controlled skin unity interruption. It is essential to be in a good health condition to make sure immune system will support prompt and efficient healing. Boosting your immunity with traditional supplements like Vit C is advisable, as well as reducing smoking and sun exposure prior and after the service. Moisturizing the aria that is going to be treated at least one-week prior scheduled appointment will assure better results and promote fast healing.

- Exacerbation of any chronic diseases is a contraindication for the service

- Diabetes is a contraindication for the service

- Pregnancy is a contraindication for the service

- Skin inflammation and other occurring inflammatory or autoimmune disease are a contraindication for the service

- Do not take Aspirin, Ibuprofen, Niacin, Vitamin E or Omega supplements 24 hours before procedure

- If you have been taking drugs for any bacterial or other inflammation schedule your appointment two weeks after the end day of your treatment.

- No alcohol or caffeine on the day of the procedure

- A sensitivity test will be advisable if there is a history of allergic reactions

- Do not use Retin-A or any other skin-peeling products close to the treated area 2 weeks prior to and after your procedure

- Since delicate skin or sensitive areas may be minor-swollen or pink, you are advised not to make social plans on the day of your appointment

- Please note that wearing make-up on a treated aria is not recommended for the minimum of 48 hours after your appointment

- Any kind of activities involving intense sweating are not recommended for at least 24 hours after the service

- Keeping the aria clean and following the aftercare are instructions is essential for smooth healing

- Removing the scab before complete healing may promote the secondary peeling or skin irritation

- Please note that you will be more sensitive during your menstrual cycle

-The National Blood Service does not accept donations of blood for 1 year after a permanent cosmetic enhancement, tattoo or removal procedures.

CLIENT MEDICAL HISTORY FORM DATE

Full Name *

Date of birth *

Address *

Phone *

Email *

Emergency Contact Name *

Emergency Contact Number *

Preferred Method of Contact *

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Do you presently have or previously had any of the following:

Recent Botox *

YES

NO

Recent Fillers/Restylane/Juvederm *

YES

NO

Keloid scar predisposition *

YES

NO

Diabetes *

YES

NO

Hepatitis (A, B, C, D) *

YES

NO

Recent Blepharoplasty (Eyelid surgery) *

YES

NO

Recent Brow lift *

YES

NO

Recent Face lift *

YES

NO

Easy bleeding (Hemophilia) *

YES

NO

Alcoholism (or daily small amount alcohol consumption) *

YES

NO

Eye surgery/injury/Corneal abrasion *

YES

NO

Abnormal Heart Condition *

YES

NO

Hormonal Disorders *

YES

NO

Abnormal Blood Pressure *

YES

NO

Psoriasis or Any Other Skin Disease *

YES

NO

Vitamins or Microelements Deficiency *

YES

NO

Autoimmune Disease *

YES

NO

Chemical Peel *

YES

NO

Pregnant now/Breast feeding now *

YES

NO

Recent Brow or Lash Tinting *

YES

NO

Slow or Problematic Skin Healing if Wounded *

YES

NO

Accutane or Other Acne Treatment *

YES

NO

Tan by Booth or Sun *

YES

NO

Taking any Medication for Chronic Disease *

YES

NO

Taking Blood Thinners such as: Aspirin, Ibuprofen, Alcohol, Coumadin, etc. *

YES

NO

Allergic reaction to any medications such as Lidocaine, Benzyl Aalcohol, Vitamin E Acetate, etc. *

YES

NO

Other medications (if yes):

Allergies to Metal, Food, etc. *

YES

NO

Other allergies (if yes):

Any Diseases or Disorders Not Listed? *

YES

NO

Other diseases or disorders (if yes):

Do you use skin care products containing Retin-A, glycolic acid or alpha hydroxyl? *

YES

NO

Please list medications, birth control peels, suplaments or vitamins you are presently taking:

I agree that all the above information is true and accurate to the best of my knowledge.

Please sign below using your mouse:

Hover your mouse over the below box *

STATEMENT OF CONSENT AND RECITALS

Please read all the lines and sign again below

Aftercare instructions have been explained to me and a copy will be given to me to refer to, which I will follow to the best of my ability. If I have questions I will call or email my technician

I understand that a certain amount of discomfort is associated with this procedure and that swelling, or redness may occur

I understand that sun, tanning beds, pools, some skin care products and medications can affect the healing process

I will tell all skin care professionals or medical personnel about my removal procedure, especially if I’m schedule for any peeling treatment less than one month after my removal appointment

I understand that implanted pigment will not magically vanish from my skin, and I need to expect a possible darkening of its colour after the first procedure. I realise that for pigment to fade I need to undergo a sequence of minimum 3 procedures that can not be performed more often than one month apart

I acknowledge that the proposed procedure involves risks inherent in its nature as the epidermal layer of my skin will be irritated and have possibilities of complications as: infections, blisters, and hyperpigmentation if I am not following the aftercare instructions, suntanning, and not treating the location of removal with the respect of common hygienic protocol

I accept full responsibility for the decision to have this cosmetic procedure to lighten the unsatisfactory tattoo work done on my face/body

I certify that I have read or have had read to me the contents of this form. I understand the risks and alternatives involved in this procedure and I have had the opportunity to ask questions and all of my questions have been answered. I acknowledge that I have reviewed and approved the material given to me and I authorise Laura McCann as my permanent cosmetics technician to perform on my face/body the following procedures.

Please sign again to confirm you have understood the statements above *

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