Valhalla Laser Release Form
Ask a staff member what to enter
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:
*
-Month-
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
-Day-
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
-Year-
1911
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
You must be 18 or older
Phone #:
*
Email:
*
Signature:
*
Sign above or type signature:
Parent/Legal Guardian
I, as parent or legal guardian of the above minor under -18 years of age, hereby consent to the terms and conditions set forth in this release form
Guardian's Legal Name:
*
Signature:
*