(For Tattoo Removal Treatment)
  • Name: * Date of Birth: *

  • Address: * City: * State: * ZIP: *

  • Phone Number: * Email: *

  • Tattoo Size Tattoo Age Is this a cover up tattoo?

  • Tattoo Location Tattoo Conditions

  • Any previous removal attempt on this tattoo: (laser, creams, self removal)

  • If yes, provide details:

  • Skin Type:

  • (if known)

  • Do you hyper-pigment when you scar?

  • Do you have any hypertrophic scar?

  • Do you have hypo-pigment when you scar?

  • Do you scar easily

  • Are you taking any Drugs or Medication?

  • Are you allergic to anything?

  • Do you have any of the following conditions? (Please check)

  • Do you have any of the following medical conditions? (Please check)


  • I, * currently have an unwanted tattoo/permanent makeup. This tattoo/permanent

    makeup is located on the * (area of the body). This area was last tattooed on * (approximate date) by* (name of the business or technician).

  • This tattoo or permanent makeup is unwanted because * (indicate the shape, color, and location). I would like the technician to attempt to; (a) * remove the entire tattoo if possible; or (b) * partially remove the tattoo (check one).

  • I understand that several treatments may be needed to attempt to achieve my desired results. I have not been given any guarantees as to the quality of the removal results.

    I understand there are several medical and aesthetic options available for the removal of my tattoo or permanent makeup. I have decided to choose the tattoo removal technique at this time.

    I understand that removing tattoos/permanent makeup is a complicated process. As a result, I will not hold the technician of this establishment responsible for any resultant failure to remove partially or totally.

    Furthermore, I will not hold the salon of the business of the technician, the distributor, and the manufacturer of the tattoo removal products used in this attempted tattoo removal liable for any damages that may occur to my face or body.

    I agree to be taken the photographs “before” and “after” the treatments and to conform to all rules and regulations established by the technician and salon listed below for the removal of an unwanted tattoo or/ permanent makeup. I agree to follow all aftercare instructions.

    I have been duly informed of the nature, risks, possible complications, and consequences listed above. I further understand that the above-listed technician is not a medical doctor and have neither asked nor received any guarantees or promises as to the results obtained.

    I understand everything described above, have had any questions answered, agree that it is all true and correct and by my signature below I agree to the above.

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