Skin Fade Laser Tattoo Removal & Skin Clinic

Pre-Consultation Form

Laser Tattoo Removal and Tattoo Fading Pre-Consultation Questionnaire

Please do not complete this form unless you have already booked an appointment.

To book an appointment you can either use the Bookings page, email us or send us a message on Facebook or Instagram.

If you have already contacted us and have a confirmed booking, please complete this questionnaire accurately and honestly.

Once completed, your answers will be submitted for your Laser Technician for assessment prior to your in-person consultation and patch test.

The answers to your questions will determine whether laser treatment is both safe and suitable for you.

Treatments and consultations are strictly by appointment only.

Absolutely NO walk-ins under any circumstances.

Tattoo Removal Pre-Consultation Questionnaire

First Name:

Surname:

Date of Birth:

Age:

Address:

Postcode:

Email:

Mobile No:

Gender:

Male

Female

Other

Which treatment(s) are you enquiring about?

Tattoo Removal

Tattoo Fading for Cover-Up

Other

How many tattoos are you looking to remove/fade?

Roughly how old is the tattoo?

Where is/are the tattoo(s) you want removed located on your body?

Roughly how big is the tattoo?

Have you had or used any of the following in the past 30 days?

Sun beds

High levels of exposure in the sun

Self tanning cream or spray tan

None

When was your last holiday where you were exposed to high levels of sun?

When is your next planned holiday where you are likely to be exposed to high levels of sun?

If you have ticked YES to ANY of the above, please provide further information below:

Please list ANY medical conditions or complications you have which have not been listed above:

Please list the names of ANY medications that you are currently taking:

Are you taking any photosensitive medications (including medications for anxiety and/or depression)?

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

Yes (currently using)

Yes (previously used)

Have you ever used, or are you currently using Roaccutane?

Yes (currently using)

Yes (previously used)

If you have any surgical implants, please list the area(s)

If you have any surgical or injectable dermal fillers, please list the area(s)

Have you had any major surgery performed in the last 3 months? If Yes, please provide details.

Do you have any skin sensitivities or allergies to latex, creams or gels?

How did you hear about Skin Fade?

Comments:

Is there anything which hasn't been covered within this consultation form which you feel may make you unsuitable for laser tattoo removal?

Informed Consent

• I hereby authorise Gary Phillips / Skin Fade Clinic to treat me using the AW3® system.

• I understand that the reduction or removal of my tattoo is not 100% guaranteed. 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 understand that there are alternative treatment possibilities and other forms of treatment available, 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 or mild tenderness.

- Although uncommon, the treatment may cause blistering or light burns to the surface of the skin.

- 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.

- Scabbing, swelling, blistering and bleeding can occur but these are temporary.

• The list of treatment(s) that will apply to me when accepting this consent are Laser Tattoo Removal and Laser Tattoo Fading.

• 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 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 at least 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 their personnel while I am under their care, realising that any lack of co-operation could result in complications or 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 before, during and after treatment.

• I certify that I have read the entire informed consent and I agree to all its provisions.

• 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. Skin Fade Clinic accepts 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.

• I confirm that the information given within this pre-consultation questionnaire is true and complete. I have taken full responsibility for completing the form and have not delegated any part of my responsibilities to any other person.

• I understand that if any medical conditions arise or if my medical circumstances change during the course of my treatments, I must inform Skin Fade Clinic immediately.

Treatment Bookings

• I understand that there is a charge of £15.00 for the consultation and patch test which will be deducted from the total cost of my first treatment session.

• If I do not book in for an appointment within 3 months of my consultation date then I accept that this fee will be forfeited.

• I also acknowledge that I may be asked to pay a deposit to secure any future bookings.

• I accept that if I am unable to attend a booked appointment that I must provide at least 4 hours' notice for my deposit to be transferred to a new booking date.

• I accept that if I provide less than 4 hours' notice (or provide no notice/no show) my deposit will be forfeited and re-booking may be refused.