Laser Tattoo Removal Consultation And Consent Form
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3Laser Tattoo Removal Consultation and Consent Form
Title ________ First Name _____________________________
Surname _____________________________________________________
Address _______________________________________________________________________________________________________________
Occupation __________________________
Email Address ____________________________________________________________
Mobile _______________________________
Home Ph _________________________________________________________________
Date of Birth __________________________
Ethnic Background ________________________________________________________
Family Doctor Name and Contact No: ___________________________________________________________________________________
Emergency Contact Name and Telephone _______________________________ Relationship ___________________________________
How did you find out about our salon? ___________________________________________________________________________________
Tattoo Information
Location of tattoo/s:____________________________________________________________________________________________________
Is the tattoo: Professional
Amateur
Traumatic
Surgical
Other:
_______________________________________
Do you have any current or chronic medical illnesses?
Yes
No
Details __________________________________________
Are you currently under a doctor’s care?
Yes
No
Details __________________________________________
Have you taken blood thinners or anti-coagulants in last 3 mths? Yes
No
Details____________________________________
Have you taken photosensitising medication in last 3 mths?
Yes No
Details ____________________________________
(ie. Anti-depressants, St. John’s Wart, Roaccutane etc?)
Do you have (or getting treated for): Cancer
Heart condition
Poor healing ability Auto-immune disorder
Have you had (in tattoo area): Chemical peel Dermabrasion Laser Surgery Other : _______________________
Do you have permanent makeup or implants?
Yes
No
Details __________________________________________
Have you got ANY type of skin tan (fake or natural)?
Yes
No
Details __________________________________________
Do you smoke?
Yes
No
If so, how many per day?
_______________________________________________
Do you have any allergies?
Yes
No
If so, please list ___________________________________________________
Client Name:
Client Signature:
Clinician:
Date:
________________________
__________________________
__________________________
______________
Kirby-Desai Scoring
Skin Type:
How would you rate your skin in the area to be treated?
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Type I
Always burn, never tan. Extremely fair skin/blonde hair/blue/green eyes
2
Type II
Usually burn, tan less than about average. Fair skin, sandy brown to brown hair, green/blue eyes
3
Type III
Sometimes burns, gradually tans about average. Medium skin, brown hair, green/brown eyes
4
Type IV
Sometimes burns, tans Light brown or olive skin, dark brown eyes and hair.
5
Type V
Rarely burns, tans profusely. Dark brown skin, black hair, black eyes
6
Type VI
Deeply pigmented, never burns. Black skin, black hair, black eyes
Location:
1 Head and neck
2 Upper trunk
3 Lower trunk
4 Proximal extremity 5 Distal extremity
Colours:
1 Black only
2 Most black, some red
3 Most black, some red & other
4 Multiple colours
Amount of Ink:
1 Amateur
2 Minimal
3 Moderate
4 Significant
Scarring and Tissue Change:
0 No scar
2 Minimal scarring
3 Moderate scarring 4 Significant scarring
Tattoo Layers:
TOTAL POINTS __________
0 No
2 Yes
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