How old is your tattoo?* Please Indicate number of Years/Months.

Professional Tattoo* Is your tattoo a professionally done tattoo ?

Tattoo Placement * Where (on the body) is your tattoo located ?

Tattoo Design Information* Please explain the design of your tattoo, as best you can.

Cover Up* Is your tattoo a cover up?

Cosmetic* Is your tattoo a cosmetic tattoo e.g Eyebrow tattooing?

Other Methods* Have you tried any other methods of tattoo removal?
If yes, please describe results below.

Suntan* Do you have Suntan ?

Consent* I give full consent to and authorize Honey Ink and members of their staff to perform multiple laser procedures,
and related services on me. The procedure planned uses laser technology for the removal of tattoos.
I am undertaking the procedure and I am prepared to take full responsibility upon myself for this procedure and
all the associated risks and release Honey Ink from all liability at all times
I understand that all Laser procedures mav have side effects.

Following side effects* 1.
Possible side effects of the procedure include but are not limited to:
pain, purpura, swelling, redness, bruising, blistering, crusting/scab formation, ingrown hairs, infection, hot sun burnt feeling and unforeseen complications which can last up to many months, years or permanently.

2.
Scarring is uncommon but it is a risk, and can be hypertrophic or even keloid, other skin texture and colour changes may occur, and other unforeseen complications may present which can last up to many months,
years and mav be permanent.

3.
Short term effects may include reddening, mild burning, temporary bruising or blistering.
a brown/redish darkening of the skin (known as hyperpigmentation) or lightening of the skin (known as
hypopigmentation) may occur. This usually resolves in weeks, but it can take up to 3-6 months to heal.
Permanent colour change is a rare side effect. Loss of freckles or pigmented lesions can occur.

4.
Textual and/or colour changes in the skin can occur and can be permanent. Many of the cosmetic tattoos and body tattoos are made with iron oxide pigments. Iron oxide can turn red-brown or black. Titanium oxide and other pigments mav also turn black. This black or dark colour may be unremovable, Because of
the immediate whitening of the exposed treated area by the laser, there can be a temporary obscuring of Ink, which can make it difficult or impossible to notice a specific colour change from the tattoo removal process. If this reaction occurs during a removal, I assume a responsibility, Other options for Tattoo removal
- Include cosmetic surgery. consultations with dermatologists

5.
Infection following laser tattoo removal is unusual however, bactenal, fungal and viral infections can
occur. Herpes simplex virus infections around the mouth can occur following a session. This applies to both
individuals with a past history of herpes simplex virus infections and individuals with no known history of herpes simplex virus infections in the mouth area. Should any type of skin infection occur, I will immediately seek medical advice, an understand that additional treatment or medical antibiotics may be required.

6.
Pinpoint bleeding is rare but may result following procedures. Should bleeding occur, additional treatment may be necessary.

7.
Hypersensitivity to the various tattoo pigments during the tattoo removal process may occur, especially if the tattoo pigment contained mercury, cobalt or chromium. Upon dissemination, the pigments can induce a severe allergic reaction that can occur with each successive application. Noted in some clients are
superficial erosions, bruising, blistering, milla, redness and swelling which can last up to many months
years or permanently.

8.
Some medications and suntans prohibit the laser tattoo removal process. Persons on Accutane and photosensitizing medications cannot be treated and it you have suntanned within the last 6 weeks or have a spray/synthetic tan you cannot be treated.

Aftercare Guildlines* I understand compliance with the aftercare guidelines Is crucial for healing, prevention of scarring, and hyperpigmentation. Aftercare guidelines include avoiding the sun for 2 months after the procedure. If it Is necessary to be in the sun, a sunscreen with SPF 50 or greater must be used.

Purpose* I understand the nature and purpose of laser tattoo removal and it has been full explained to me.
I have read and understand this agreement.
All of my questions have been answered to my satisfaction and
I consent to the terms of this agreement Alternative methods of tattoo removal and the risks and benefits of laser tattoo removal have been explained to me and i understand l that i have the right to refuse to undergo laser tattoo removal.

Sessions* I understand that multiple sessions will be necessary to achieve desired results. No guarantee warranty or assurance has been made to me as to the results that mav be obtained. I understand results vary from person to person and and that complete tattoo removal is not always possible.

Photography* I give full permission for a photo (s) of my tattoo, before and after laser removal to be taken by Honey Ink to use, reproduce and publish for commercial purposes. No names or facial recognition photos will be published.

Acknowledgment* I have had the full process explained to me and I fully understand what is involved. I have read and received
a copy of the aftercare instructions. My questions regarding the procedure have been answered satisfactorily,
I understand the procedure and accept all risks. I hereby release Honey Ink and all Honey Ink staff from all liabilities with my procedure.

Waive* I understand that tattoos are an art form meant to last a lifetime. I have read the fact Sheet and understand It
fully. I have read and understood the informed Consent and Waiver Forms and signed both forms. I understand
that no warranties, no guarantees, no refunds, and no forecast as to the number of removal sessions required
can be given, and that no outcomes of each session can be given.

Emergency * In the event that the practitioner reasonably believes emergency medical assistance is required,
I authorise the practitioner and/or studio staff to contact emergency services (000) and seek appropriate medical treatment on my behalf.


I understand that any costs associated with ambulance transport, hospital treatment, medical assessment, or other healthcare services are my responsibility.

And consent to have your emergency contact contacted on your behalf?