Laser Removal Consultation Form

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Let us do this part

Today's Date:

Sat Apr 4 2026 01:01

Practitioner:*

Signature:*

Please read and answer

Treatment Area *

Have you used any of the following in the past 30 days? *

None

Sun Beds

Self-tanning Cream

Tanning in the Sun

When was your last sun holiday? *

When is your next sun holiday? *

Please specify any medical condition that is not listed above:

Please list any medication you are currently taking; *

Have you ever used (or currently using) Retin A or Glycolic Acid? *

Have you ever used (or currently using) Roaccutane? *

What products are you currently using on your skin? This includes both face and body products; *

Do you have any implants? If yes, please state where; *

Details:

Do you have any skin sensitivities or allergies? If yes, please specify; *

Details:

Have you had any major surgery performed in the last 3 months? If yes, please specify; *

Details:

By completing this consultation form, I hereby authorise Samsara Ink Laser Tattoo Removal technician to treat me using the AW3 System.

I have been informed about alternative treatment possibilities and I understand that other forms of treatment or no treatment at all, are choices that I have.

I understand that there are certain risks associated with the treatment and they include but are not limited to the following;
* Post-treatment discomfort like localised swelling, redness and mild tenderness.
* Although uncommon the treatment may cause blisters or light burns to the surface of the skin. (Light /Laser Treatment Only)
* Transient hypo or hyper pigmentation may occur and will normally fade in 3 to 6 months.
* Crust formation "dirty skin" look is commonly seen for up to 10 days after treatment. (Light /Lases Treatment Only)
* Scabbing, Swelling, and bleeding can occur but these are temporary. (Light /Laser Treatment Only)

Below are a list of treatments) that will apply to me when accepting this consent.

Laser Tattoo Removal/ Pigmentation/ Thread Vein/ Rejuvenation/ Birthmark Removal

Laser treatment is a method of removing tattoos. The purpose of the treatment is to achieve improvements in the appearance of the skin by removing the unwanted tattoo/pigment within the dermis of the skin using the AW3® Laser system.

Accepting Terms and Consent*
i. I agree to follow the post treatment recommendations advised by operator/company above in order to ensure the best possible results. For Light/ Laser Treatments, I understand that excessive heat should be avoided for 48 hours and that exposure to the sun, including sun beds, must be avoided for 30 days, before treatment and 30 days after treatment. A sun block of SPF 30+ must be used on the exposed skin areas, otherwise it might be possible that blotchy skin pigmentation, hyper- or hypo-pigmentation might occur.

ii. I agree to co-operate with the recommendations of the company or the personnel while I am under their care, realising that any lack of co-operation could result in less than optimum results.

iii. I agree to inform the above operator/company immediately if any adverse effects occur.
I agree to photographic documentation of the treated area prior to treatment.

iiii. I certify that I have read the entire informed consent and I agree to all its provisions. I certify that I have had the opportunity to ask questions and these questions have been answered to my satisfaction. I fully understand the treatment conditions and procedure.

iiiii. I agree to pay for the above mentioned services and understand that there will be no refunds for any performed services. This consent form and cost covers above selected treatments only. Additional treatments can be added to this consent form and will be charged for as per clinic price list, including single shot treatments.

iiiiii. I have been made aware of the risks and I accept these terms and conditions as part of my treatment. We accept no liability for any of the above side effects. By accepting this, I agree to the terms and conditions and in the event of any of the above. I or any of my representative will not pursue the above person / company in any means of compensation.

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.

Client Information

I hereby declare that I am of legal age (with valid proof of age) and am competent to sign this Agreement.

Name:*

Address:*

Postcode:*

Date of birth:*

You must be 18 or older

Age:

Gender:

Nationality:

Phone #:*

Email:*

Signature:*

Sign or type signature:

Emergency Contact

If something happens, your emergency contact might need to explain your medical history, allergies, or medications.

Name:

Phone #:

Email:

Photo Identification *

Please take photo(s) of your government issued photo IDs and related paperwork