Consent Form – Ink’d Away

Date

First Name *

Last Name *

Street Address *

City

County

Postal Code *

Email Address *

Contact Number *

Date of Birth *

Day

Month

Year

Age

Gender

1) Which treatment and what areas (e.g. legs) are you interested in having?

2) What form of treatment have you used in the past to get rid of the above?

3) When last did you have any of the above treatments?

4) How does your skin react to these treatments?

5) What are your goals and expectations of the treatment?

6) How often do you sunbathe?FrequentlySometimesRarely

7) Without any protection cream, how does your skin respond to sun?Always burnSometimes burn, always tanAlways burn, sometimes tanNever burn, always tan

8) Have you used any of the following in the past 30-60 days?Sun bedsSelf tanning creamTanning in the sun

9) When was your last sun holiday, and when is your next sun holiday?

12) Are you currently being treated for a condition not listed?

Yes, please specifyNo

13) Are you currently taking any medication?

Yes, please specifyNo

14) Have you ever used (or currently using) Retin A or Glycolic Acid?YesNo

15) Have you ever used or are you currently using Roaccutane?YesNo

16) Have you ever had a chemical peel?YesNo

17) Have you ever had any laser treatments in the last 6 months?

Yes, please specifyNo

18) What products are you currently using on your skin (including body products)?

19) Do you have any implants?

Yes, please specifyNo

20) Do you have any tattoos or permanent make-up on the areas that you want to be treated?YesNo

21) Have you ever been treated by an endocrinologist (hormonal threatments)?YesNo

22) Do you have any particular skin sensitivities or allergies?

Yes, please specifyNo

23) Have you had any major surgery performed in the last 3 months?

Yes, please specifyNo

24) Ladies only – What was the date of your last menstrual cycle?

25) Have you read and understood all the information given to you in your Treatment Information Package, including contra-indications? *YesNo

I hereby authorise Ink’d Away to treat me using the AW3® system. I understand that the reduction / removal may not be 100%. I also understand that the treatment using the AW3® system may need to be performed in repeated sessions in the future to obtain optimal results. I have been informed about alternative treatment possibilities and I understand that other forms of treatment or no treatment at all, are choices that I have. I understand that there are certain risks associated with the treatment and they include but are not limited to the following: Post-treatment discomfort like localised swelling, redness and mild tenderness. Although uncommon the treatment may cause blisters or light burns to the surface of the skin. (Light/Laser Treatment Only) Transient hypo or hyper pigmentation may occur and will normally fade in 3 to 6 months. Crust formation “dirty skin” look is commonly seen for up to 10 days after treatment. (Light /Laser Treatment Only) Scabbing, Swelling, and bleeding can occur but these are temporary. (Light /Laser Treatment Only) Below are a list of treatment(s) that will apply to me when accepting this consent. Laser Tattoo Removal/ Pigmentation/ Thread Vein/ Rejuvenation/ Birthmark Removal Laser treatment is a method of removing tattoos. The purpose of the treatment is to achieve improvements in the appearance of the skin by removing the unwanted tattoo/pigment within the dermis of the skin using the AW3® Laser system. Accepting Terms and Consent* I agree to follow the post treatment recommendations advised by operator/company above in order to ensure the best possible results. For Light/ Laser Treatments, I understand that excessive heat should be avoided for 48 hours and that exposure to the sun, including sun beds, must be avoided for 30 days before treatment and 30 days after treatment. A sun block of SPF 30+ must be used on the exposed skin areas, otherwise it might be possible that blotchy skin pigmentation, hyper- or hypo-pigmentation might occur. I agree to co-operate with the recommendations of the company or the personnel while I am under their care, realising that any lack of co-operation could result in less than optimum results. I agree to inform the above operator/company immediately if any adverse effects occur. I agree to photographic documentation of the treated area prior to treatment. I certify that I have read the entire informed consent and I agree to all its provisions. I certify that I have had the opportunity to ask questions and these questions have been answered to my satisfaction. I fully understand the treatment conditions and procedure. I agree to pay for the above mentioned services and understand that there will be no refunds for any performed services. This consent form and cost covers above selected treatments only. Additional treatments can be added to this consent form and will be charged for as per clinic price list, including single shot treatments. I have been made aware of the risks and I accept these terms and conditions as part of my treatment. We accept no liability for any of the above side effects. By accepting this, I agree to the terms and conditions and in the event of any of the above. I or any of my representative will not pursue the above person / company in any means of compensation.

Save as Draft