TATTOO REMOVAL CONSENT & RELEASE FORM

REBEL INKS TATTOOS, TATTOO REMOVAL, AND BODY PIERCINGS PARLOUR

1. CLIENT INFORMATION

Full Name *

Date of Birth *

If under 18, Parent/Guardian’s Name

ID/Passport No. *

Phone Number *

Email *

Emergency Contact (Name & Phone) *

2. TATTOO INFORMATION

Tattoo Location on Body *

Approximate Size *

Tattoo Colors Present

Age of Tattoo *

Was the Tattoo Professionally Done? *

Yes No

3. MEDICAL & HEALTH QUESTIONNAIRE

Please check YES or NO to the following questions:

Are you currently pregnant or breastfeeding? *

Yes No

Are you taking any prescription medications? *

Yes No

Do you have diabetes, heart problems, or immune disorders? *

Yes No

Do you have any skin conditions (eczema, psoriasis, rash, infection) in the area? *

Yes No

Do you have a history of scarring, keloids, or poor wound healing? *

Yes No

Do you have a history of seizures, fainting, or sensitivity to light? *

Yes No

Have you recently had sun exposure, tanning, or used self-tanners on the area? *

Yes No

Do you have any known allergies (e.g., to lidocaine, antiseptics, adhesives)? *

Yes No

Have you had any other tattoo removal or skin treatments on this area before? *

Yes No

Do you have any communicable diseases (Hepatitis, HIV, etc.)? *

Yes No

If you answered “YES” to any question above, please explain: *

4. CLIENT ACKNOWLEDGEMENT & UNDERSTANDING

5. AFTERCARE CONFIRMATION

- All equipment used during the procedure is sterilized and single-use. - The piercing area is cleaned and disinfected according to professional hygiene standards. - The jewelry used is implant-grade, nickel-free, and safe for body wear. - The piercer will provide verbal and written aftercare instructions for healing and hygiene.

6. AFTERCARE CONFIRMATION *

- Keeping the area clean and dry. - Avoiding direct sun exposure, swimming, and harsh products for at least 7–10 days. - Applying provided ointment as directed. - Avoiding scratching or picking the treated area. - Contacting the studio if excessive redness, swelling, or infection occurs.

7. PHOTO CONSENT (OPTIONAL) *

I consent to photographs of my treated area being used for the studio’s professional documentation, social media, or marketing (without identifying me). I do not consent to photographs being used for any purpose.

8. CONSENT & RELEASE

Field Name

I hereby consent to receive laser tattoo removal treatment at my own risk. I understand that results vary based on tattoo ink, age, and my skin’s healing ability. I release the technician, studio, and its representatives from any claims, damages, or complications that may arise during or after treatment.

Message Us

Name *

Email *

Phone No. *

Sex *

Male Female

Please Select Your Service *

What would you like to get done *

Disclaimer: This is not a confirmed schedule, details provided will aid our specialists in planning a convenient time schedule that favours both parties when they get in touch with you for clarification.

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