1
Step 1
Saline Removal
Please read the information below and fill out your personal consent declaration.
Full Name
Date of Birth
date_range
Address
Postcode
Contact Number
Email
email
Artist
Select An Option
Bell
Kornela
Charlotte
Health Questionnaire
Are you pregnant or breastfeeding?
Yes
No
Are you prone to keloid scarring?
Yes
No
Are you currently or have you taken any medication containing Isotretinoin (e.g., Roaccutane) within the past 12 months?
Yes
No
Do you have any conditions that could affect your immune system e.g., Hepatitis C Virus (HBC). Hepatitis B Virus (HBC), AIDS, HIV infection?
Yes
No
Are you currently on any form of immune suppressant therapy that may cause delayed healing e.g. Chemotherapy, radiation?
Yes
No
Are you allergic or sensitive to any local or topical anaesthetic?
Yes
No
Are you allergic or sensitive to any local or topical anaesthetic (including dental anaesthetics)?
Yes
No
Do you have or have you ever had any heart or blood pressure problems?
Yes
No
Do you have any allergies?
Yes
No
Are you allergic to latex?
Yes
No
Are you sensitive to any regular makeup, hair dyes or any other dyes?
Yes
No
Are you currently taking any medication to treat the following which may effect blood coagulation during the procedure:
Blood thinners
Sleeping pills
Blood pressure medications
Chemical peels
Diuretics
Hormone replacement
Antibiotics
Tranquilizers
Painkillers (Aspirin/Ibruprofen)
Fainting/dizzy spells
Diabetes
Cortisone (inhaler/cream)
SPMU Declaration: ALL sections must be ticked, to proceed.
I understand that the therapist will administer a Salt & Saline mixed solution, to reduce/fully remove pigmentation of the desired area.
Yes
No
I hereby declare that I am not diabetic.
Yes
No
I hereby declare that I do not suffer from Keloid Scarring.
Yes
No
I hereby declare that I am not hemophiliac.
Yes
No
I hereby declare that I am not allergic to lodine.
Yes
No
I hereby declare that I do not test positive for the HIV or Hepatitis Viruses.
Yes
No
I hereby declare that I am not pregnant / breastfeeding.
Yes
No
I hereby declare that I have had no Botox treatments for the past 28 days.
Yes
No
I hereby declare that I have had no Filler Injections for the past 3 months.
Yes
No
I hereby declare that I am not under treatment for Cancer / Radiation / Chemotherapy.
Yes
No
I hereby declare that I am aware there is NO GUARANTEE for the outcome of my procedure.
Yes
No
I hereby declare that I do NOT have any of the Medical Conditions that were mentioned in the above
Yes
No
Indemnity Form
I hereby declare that I am under FULL UNDERSTANDING that the procedure is a Salt & Saline tattoo removal and further sessions are typically vital to achieve best results
I hereby declare that I am aware the full results will only be visible after each session has healed (4-6 weeks)
I authorize the use of my photographs taken by the technician to be used on social media and shown to potential clients.
I hereby declare that I have been informed, in detail about the procedure which will be performed. I was informed that needles are used for the treatment to inject salt & saline solution into the upper layers of the skin.
I am aware that the treatment with the needles can cause skin irritation and minor inflammation of the skin which usually disappears within 24-36 hours.
I have been informed that medicines affect different individuals in different ways.
In some cases, side effects can occur such as allergic reactions.
I hereby declare that I have been provided with, and I understand the aftercare needs for this treatment.
I undertake not to make a claim against the therapist and salon and do hereby indemnify and hold the said business, its Owner and Employees harmless in respect of any claim or damage suffered by me in the consequence of undergoing the Salt & Saline Tattoo Removal procedure.
Consent to Saline Removal
Select An Option
I consent to saline removal treatment
Full Name
Date
today's date
date_range
Submit Form
*Check Junk Mail For Your Copy*
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