TATTOO REMOVAL CONSULTATION FORM

PLEASE NOTE THAT THIS IS ONLY OFFERED AT OUR MEDICAL SPA AT OUR DAVIS LOCATION

LIGHTENING AND/OR EXTRACTION OF PRE-EXISTING TATTOO INK

The nature, method and all risks of the proposed tattoo ink lightening or removal procedure has been explained to me. Client was given full opportunity to ask any questions.

Client understands that there may be a certain amount of discomfort or pain associated during and after the procedure. Other rarely occurring adverse side effects may include but are not limited to lightening or darkening, scarring, or infection of the skin.

Client clearly understands ALL THE RISKS involved and the likelihood of any adverse reactions to the procedure. Xtract will work with you to help achieve the best results possible.

Client understands there are other medical options, including laser, available for removal of ink or pigment. Client havs decided to decline those methods.

Client understands that several treatments may be needed in order to achieve their desired results; however, they understand that there is no guarantee or assurance as to the ultimate outcome or result of this procedure. Client understands that once the procedure is completed, Xtract, has a NO REFUND POLICY.

Client understands will not hold my technician, Xtract, or any owners, employees or independent contractors of Xtract, liable for any damages that may occur to my person.

Client understands that the complete removal of tattoos is difficult.  As a result, they will not hold their technician or this establishment responsible for any resultant failure to lighten or remove completely the unwanted ink.

Client agrees to follow all instructions concerning the care of their tattoo removal procedure area, while healing. Client agrees that any complications resulting from their negligence, is totally their responsibility.

Client understands that they will be given written instructions for post-procedure care and follow up, and also understand that theyI will make a 48-hour wound check appointment.

Client agrees to submit to before and after photographs and they give permission to use such photographs for publication and/or for teaching purposes only upon signing an additional release form.

Client understands all information listed above, have had all my questions answered and agree to all conditions and provisions of this document as evidenced by my signature below. Client accepts the risks for having this procedure done and Client voluntarily requests that the tattoo lightening and removal procedure(s) are to be performed on them.

Client understands that they are a model and students will be working on their tattoo removal with the supervision of a trainer. Client understands the discount given to me will continue for any further treatments if needed. Client also understands that they will keep their technician updated during their healing process, which will include pictures.

Name *
Name
DOB *
DOB
Preferred Phone Number *
Preferred Phone Number
Address *
Address
SIGNATURE
By filling your name in here, you have officially signed this document. *
By filling your name in here, you have officially signed this document.