Valhalla Laser Release Form

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Today's Date:
Tue Jan 19 2021 08:14
VALHALLA LASER CLINIC
22 NELSON STREET
KILMARNOCK
KA1 1BD
Please read and answer
Y
N
COVID19*
DO YOU HAVE ANY OF THE FOLLOWING SYMPTOMS?
- a fever
- flu-like symptoms
- shortness of breath
- loss of taste/smell

or

Have been in contact with anyone with Covid Symptoms within the last 15 days

PLEASE NOTIFY YOUR LASER OPERATOR IMMEDIATELY TO RESCHEDULE YOUR APPOINTMENT
Y
N
Medical*
Do you suffer from any of the following conditions or take any medication? If so, please advise prior to treatment;

Porphyria (light sensitive skin)
Psoriasis
Dark Moles
Eczema.Dermatitis
Keloid/Hypotrophic Scarring
Skin Caner
Tumours
Diabetes
Epilepsy
Hemophilia
Heart Condition
Pregnant
Mental Impairment

Details:
 

Y
N
Bloodbourne Pathogens*
If you have any bloodbourne pathogens, transmittable diseases or recent illnesses, please advise prior to treatment
Details:
 

 
How did you hear about us?*
 

Payment*
Valhalla Laser Clinic is currently CASH ONLY

Consultation including patch test is £5

Cost for all other treatments will be confirmed prior to your first appointment
Eaten*
Please ensure you eat prior to your appointment, this will help maintain your sugar levels
Healing*
Common Reactions;

Whitening of the skin immediately after treatment
Bleeding
Blistering
Red/Raised Skin at treatment site


Scarring is not a common side-effect unless the area has become infected, please ensure you keep the area clean and apply germolene if any blistering appears

If you have any adverse reactions, please notify your technician as soon as possible


Fading*
Fading of the tattoo ink will generally become apparent after 2-3weeks.
I recommend leaving 6 weeks between appointments for maximum fading with minimum amount of skin trauma & cost.

The average sessions required for an amateur tattoo is between 8-10 (based on black ink) and 14 for professional

Everyone's skin is different and will react/respond differently, we will take a photo at each session to monitor progress & adjust laser fluence for best results
Influence*
I am not under the influence of alcohol or drugs, and I am voluntarily submitting to be lasered without duress or coercion.
Questions*
I acknowledge that I have been given adequate opportunity to read and understand this document, that any and all of my questions have been answered, that it was not presented to me at the last minute, and I understand that I am signing a legal contract waiving certain rights to recover against the technician and clinic/studio
Photography*
I release all rights to any photographs taken of me and the tattoo and give consent in advance to their reproduction in print or electronic form. (If you do not tick this provision, please advise your technician)
Waive*
TO WAIVE AND RELEASE to the fullest extent permitted by law the operator & studio/clinic from all liability whatsoever, for any and all claims or causes of action that I, my estate, heirs, executors or assigns may have for personal injury or otherwise, including any direct and/or consequential damages, which result or arise from my laser, whether caused by the negligence or fault of either the operator or Studio/Clinic, or otherwise.
IMPORTANT*
Please avoid;

During course of treatment:

Sunbed


For 72hours:

Saunas
Steamrooms
Excessive exercise
Fragranced products

If any provision, section, subsection, clause or phrase of this release is found to be unenforceable or invalid, that portion shall be severed from this contract. The remainder of this contract will then be construed as though the unenforceable portion had never been contained in this document.
Personal Info
I hereby declare that I am of legal age (with valid proof of age) and am competent to sign this Agreement.
Name:*
Address:
Date of birth:*
You must be 18 or older
Phone #:*
Email:*
Signature:*