PERSONAL HISTORY

MEDICAL HISTORY

MEDICATIONS

HISTORY

WOMAN CLIENTS ONLY

INFORMED CONSENT FOR LASER TATTOO REMOVAL

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 less than .05% 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. Textual 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, redness and swelling which can last up to many months, years or permanently.
8. I understand that exposure of my eyes to 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.

ACKNOWLEDGMENT
My questions regarding the procedure have been answered satisfactorily. I understand the procedure and I accept the risks. I hereby release Jacqueline Gibbs and Bye Bye Ink from all liabilities associated with the above indicated procedure.

DISCLAIMER
All sales are final and non-refundable. Tattoo Removal Sessions are valid for one year from the original purchase date. Clients are limited to ONE sale and/or discount per tattoo.

Tattoo(s) Description

Microblading/Eyebrow Tattoos ONLY

We strive to render excellent customer service and treatment(s) to all our clients. In an attempt to be consistent with this, please understand that our schedule is appointment based. When an appointment is scheduled, that time has been set aside for you and when it is missed, that time cannot be used to treat another patients.

24-Hour Cancellation Policy:
Please be advised all clients are subject to our 24-Hour cancellation policy. If you are unable to keep your appointment, our office requires a 24-hour courtesy notification before the reserved appointment date and time. If your appointment was made within 24 hours, you have a grace period of four hours to cancel and/or reschedule without penalty.

We ask that all new and current clients supply a credit card and Photo ID to have on file. In the event that we do not receive the required 24-Hour notice for adjustments and cancellations, please be advised that you will be responsible for the following terms and conditions:

Please notify our office via Phone/Voicemail (347) 396-5234 or by E-Mail: info@wordpress-1083618-3869124.cloudwaysapps.com

A missed call without leaving a voicemail and/or not confirming to the Mindbody software’s automated email and text appointment reminder DOES NOT cancel your appointment.

Notification given at least 24 hours prior to your appointment will receive no charges.

Notification given less than 24 hours prior to appointment time will result in 50% of the scheduled service price and/or lose a pre-paid package session.

Failure to show up for your appointment without notification will result in a 100% charge of the reserved service price.

If the card declines, a hold will be put on your profile in our system. Please note ALL FEES must be paid in order to book a new appointment.

Late Arrivals:
We make every effort to be on time for all our appointments. Unfortunately, when even one patient arrives late, it can throw off the entire schedule for that session.

Clients arriving more than 15 minutes after their appointment time will be liable for a $15 late fee

Thank you for your understanding. We appreciate your business and time and trust you respect mine.