Removal Consult Form

Removal Consult Form

Personal History

Which of the following best describes your skin type? (Select one or more if unsure)

Always burns, never tansAlways burns, sometimes tansSometimes burns, always tansRarely burns, always tansBrown, moderately pigmented skinDeeply pigmented, never burns

Medical History

Are you currently under the care of a physician or dermatologist?

YesNo

Do you have a history of Erythema, or Eczema or any persistent skin rash by prolonged or repeated exposure to moderately intense heat or infrared irritation?

YesNo

Do you have any of the following medical conditions? (Please check all that apply)

HepatitisCancerDiabetesHerpesFrequent Cold SoresHIV/AIDSKeloid ScarringSkin Disease/Skin LesionsBlood Clotting AbnormalitiesSeizure DisorderHigh Blood PressureAny Active Infection

Have you ever had an allergic reaction to any of the following? (Please check all that apply)

FoodLatexAspirinLidocaineCoconut Oil

Medications

What oral medications are you presently taking?

Birth control pillsHormones

Have you ever used any prescribed oral acne medication (Accutane, Epiduo, etc.)?

YesNo

History

Have you ever had any type of laser treatments in the past?

YesNo

Do you smoke cigarettes or tobacco regularly?

YesNo

Have you recently used any self-tanning lotions or treatments?

YesNo

Do you form thick or raised scars from cuts or burns?

YesNo

Do you have hyper pigmentation (darkening of the skin) or hypo pigmentation (lightening of the skin or marks after physical trauma)?

YesNo

Women Only

Are you pregnant or trying to become pregnant?

YesNo

Are you breastfeeding?

YesNo

I certify that the preceding medical, personal and skin history statements are true and correct. I am aware that it is my responsibility to inform the technician, esthetician, therapist, doctor or nurse of my current medical or health conditions and to update this history. A current medical history is essential for the caregiver to execute appropriate treatment procedures.

Informed Treatment Consent for Laser Tattoo Removal

I consent to and authorize Ink Cemetery and members of his/her staff to perform multiple treatments, laser procedures and related services on me. The procedure planned uses laser technology for the removal of tattoos.

As a patient you have the right to be informed about your treatment so that you may make the decision whether to proceed for laser tattoo removal or decline after knowing the risks involved. This disclosure is to help to inform you prior to your consent for treatment about the risks, side effects and possible complications related to laser tattoo removal.

The following problems may occur with the tattoo removal system:

  1. The possible risks of the procedure include but are not limited to pain, purpura, swelling, redness, bruising, blistering, crusting/scab formation, ingrown hairs, infection, and unforeseen complications which can last up to many months, years or permanently.
  2. There is a risk of scarring. Scarring happens but is uncommon. Scarring can be permanent.
  3. Short-term effects may include reddening, mild burning, temporary bruising or blistering. A brownish/red darkening of the skin (known as hyper pigmentation) or lightening of the skin (known as hypo-pigmentation) may occur at times up to 3-6 months, years or permanently following treatment. Loss of freckles or pigmented lesions can occur.
  4. Textural changes in the skin can occur and can be permanent.
  5. Infection: Although infection following treatment is unusual, bacterial, fungal and viral infections can occur. Herpes simplex virus infections around the mouth can occur following a treatment. This applies to both individuals with a past history of herpes simplex virus infections and individuals with no known history of herpes simplex virus infections in the mouth area. Should any type of skin infection occur, additional treatments or medical antibiotics may be necessary.
  6. Bleeding: Pinpoint bleeding is rare but can occur following treatment procedures. Should bleeding occur, additional treatment may be necessary.
  7. Allergic Reactions: Upon dissemination, the pigments can induce a severe allergic reaction that can occur with each successive treatment. Noted in some patients are superficial erosions, bruising, blistering, milia, redness and swelling which can last up to many months, years or permanently.
  8. I understand that exposure of my eyes to the light could harm my vision. I must keep the eye protection goggles on at all times.
  9. Compliance with the aftercare guidelines is crucial for healing, prevention of scarring, and hyper-pigmentation.

Occasionally, unforeseen mechanical problems may occur and your appointment will need to be rescheduled. We will make every effort to notify you prior to your arrival to the office. Please be understanding if we cause you any inconvenience.

Acknowledgement

My questions regarding the procedure have been answered satisfactorily. I understand the procedure and I accept the risks. I hereby release my technician & Ink Cemetery from all liabilities associated with the above-indicated procedure.

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Ink Sanctuary Hours

Monday -Thursday 12:00 pm-10:00 pm
Friday-Saturday 12:00 pm-11:00 pm
Sundays 12:00 pm-6:00 pm

Ink Cemetery Hours

Monday - Friday 11:00 am - 6:00 pm
Saturday 1:00 pm - 6:00 pm
After hours by appointment only.

3B Grant Avenue
Islip, NY 11751

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