THE LASER SPECIALISTS
OUR EQUIPMENT & QUALIFICATIONS
SERVICES & PRICING
FAQ
CONTACT US
CONSENT FORM
01252 507 115
CONSENT FORM
Our Consent Form
Consent Form
Name:
Email:
Phone:
Date of Birth - ID may be required
Pregnant (or planning pregnancy)
Yes
No
PCOS/ Hormonal imbalance
Yes
No
Sun Tanned/ using sun beds or fake tan
Yes
No
Thyroid condition
Yes
No
Skin pigmentation disorders (e.g. melasma, vitiligo)
Yes
No
Regular smoker
Yes
No
History of cancer (or chemo/radio therapy)
Yes
No
Psoriasis/ eczema
Yes
No
Diabetes
Yes
No
Epilepsy
Yes
No
Lymphatic/ immune system disorders
Yes
No
History of keloid formation/ scarring
Yes
No
Lupus
Yes
No
Communicable diseases (hepatitis/ HIV)
Yes
No
Depression/ anxiety
Yes
No
Herpes (shingles/ cold sores)
Yes
No
High blood pressure
Yes
No
Photosensitive conditions
Yes
No
Allergies - Please specify
Units alcohol per week - please specify
Ethic Origin - Please specify
Please indicate how your skin responds to midday summer sun exposure with no sunscreen:
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
Have you used any self-tanning products in the last 2 weeks prior to your appointment?
Yes
No
Have you used in the last 3 months or are you currently using any of the following?
St Johns Wort
Amiodarone
Minocycline
Gold medications
Oral/Topical Retinoids e.g - Roaccutane or Retin A
Are you currently taking any medication and/or supplements? Please specify below
Are you recovering from any major medical treatment or photodynamic therapy (PTD) within the last 6 months? If yes please specify
Have you ever suffered from any skin disorder/ disease?
Yes
No
Have you previously had Laser or IPL treatment?
Yes
No
What are your goals/expectations from the treatment?
Tattoo Assessment - Colour - Please specify
Tattoo Assessment - Type - Please choose from the below
Professional
Amateur
Cosmetic
Traumatic
Temporary / Semi-permanent
Please read this consent form and Tick to indicate you understand and accept the information contained herein. The information I have given is correct to the best of my knowledge and I have not withheld any known medical state or condition. I will inform the IPL? Laser operator before treatment if there has been any change (for example in medications taken) I understand that the results from this treatment vary considerably and a small percentage of people will not respond satisfactory to treatment I understand multiple treatments are necessary to achieve satisfactory results. I understand there is no guarantee of permanent results and maintenance treatments may be necessary. I understand that I must avoid sun exposure on the treated area for the duration of the treatment (and for up to 1 month afterwards) or use a high sun protection factor to avoid sun damage, I understand that tanned skin cannot be treated. I understand that there may be short-term side effects such as reddening, bruising, swelling, mild burning or blistering, hypo- pigmentation, (lightening of the skin) or hyper- pigmentation, (darkening of the skin) as well as rare side effects such as scarring and permanent discolouration. I understand that pigmented areas caused by sun damage may initially turn darker. This will be followed by ‘micro-crusting’ of the lesion, after which it should flake away leaving an area without excess pigmentation. I understand that I must wear protective eye goggles to prevent damage from the light. I certify that I have read and understood all the information and my questions have been answered satisfactorily before signing this consent form. I consent to the terms of this agreement.
I AGREE TO THE ABOVE
Full name
Date
Thank you for contacting us.
We will get back to you as soon as possible.
Oops, there was an error sending your message.
Please try again later.
No treatment will be carried out without our
consent form
having been completed.
Contact Us
Name:
Email:
Phone:
Message:
Thank you for contacting us.
We will get back to you as soon as possible.
Oops, there was an error sending your message.
Please try again later.
01252 507 115
The Laser Specialists
2 Bridge Rd, Farnborough
GU14 0HS, UK
https://www.yell.com/biz/boutink-tattoo-studio-farnborough-7574843
Terms of Use
|
Privacy & Cookie Policy
|
Trading Terms
| Powered by
Yell Business
© 2024. The content on this website is owned by us and our licensors. Do not copy any content (including images) without our consent.
Share by: