#103 7228 192 St Surrey BC
778-889-0620
Tattoo Removal Consent Form
Client Name
(Required)
Full Name
Phone
(Required)
Email
(Required)
DOB (18+ only)
(Required)
MM slash DD slash YYYY
Procedure Area:
(Required)
Brows
Lips
Eyeliner
Small Tattoo
Medium Tattoo
Large Tattoo
Full Body
MEDICAL HISTORY (YES / NO):
Are you pregnant?
(Required)
Yes
No
Breastfeeding?
(Required)
Yes
No
On Accutane?
(Required)
Yes
No
Active skin issues?
(Required)
Yes
No
Prone to keloids?
(Required)
Yes
No
On blood thinners?
(Required)
Yes
No
Medical issues affecting healing?
(Required)
Yes
No
Recent tan/sunburn?
(Required)
Yes
No
CONSENT & ACKNOWLEDGEMENT
Results vary by skin type, pigment depth, and aftercare. No guarantee of full removal.
Possible risks: redness, swelling, blistering, scarring, pigment changes.
I confirm I am not pregnant, not breastfeeding, and not on restricted medications.
I take full responsibility for accurate medical disclosure.
Laser Club & Beauty Bar is not liable for adverse reactions from undisclosed conditions or improper aftercare.
All payments are non-refundable regardless of results or number of sessions.
IMPORTANT INFORMATION FOR TATTOO REMOVAL CLIENTS
Healing Expectations
Swelling, redness, whitening, peeling, itching, and mild discomfort are normal.
Aftercare Responsibilities
Keep area clean/dry. No gym, steam, sauna for 48 hours.
Avoid sun for 2 weeks. No makeup 24–72 hours.
Pigment Colour Change
Ink may temporarily turn orange, red, grey, or blue before fading.
Medical Emergency Disclaimer
If excessive swelling, fever, or infection occurs, client must seek medical attention.
Sun Exposure Warning
Sun before/after treatment may slow healing or cause pigmentation issues.
Session Count Disclosure
Number of sessions cannot be predicted. No refunds or free sessions.
PMU Rework Disclaimer
Any PMU after removal is a separate charge.
Pain Level Variation
Pain tolerance differs; no guarantee of comfort level.
Ink Type Limitations
Certain colours (green, blue, white) may not fully break down.
Patch Test (Optional)
I want a patch test
I decline patch test and accept all risks
CONSENT & LIABILITY WAIVER
(Required)
CONSENT & LIABILITY WAIVER By submitting this form, I agree to the following terms regarding my treatment at RK Beauty Club. 1. Informed Consent, Capacity & Voluntary Decision I confirm that I am 18 years of age or older (or have a legal guardian present) and have the legal capacity to consent. I have read and understood the details of the treatment I am requesting. I have had the opportunity to ask questions regarding the procedure, risks, benefits, alternatives, and expected outcomes, and all questions have been answered to my satisfaction. I confirm that I am choosing this treatment voluntarily, without coercion, and I understand I may withdraw my consent at any time before or during the procedure. 2. Medical Accuracy & Responsibility I certify that the medical history and health information I have provided is truthful, accurate, and complete. I understand that undisclosed conditions, allergies, or medications (e.g., blood thinners, Accutane) may affect my safety and the treatment outcome. I assume full responsibility for any adverse reactions resulting from my failure to disclose such information. 3. Risk Acknowledgement & No Guarantees I understand that all aesthetic procedures carry inherent risks, including but not limited to: pain, redness, swelling, blistering, scarring, discoloration, sensitivity, infection, allergic reactions, and healing variations. I acknowledge that results are not guaranteed, may vary by individual, and that "touch-ups" or additional sessions may be required at my own expense. 4. Aftercare Commitment I agree to strictly follow all pre- and post-treatment instructions provided by RK Beauty Club. I understand that failure to follow these instructions may increase the risk of complications, infection, or altered results, for which the clinic cannot be held responsible. 5. Financial Policy & Refunds I understand and agree to the clinic’s financial policy. I acknowledge that all payments and deposits are non-refundable (except where required by law). I also agree to provide at least 48 hours' notice for cancellations to avoid forfeiture of deposits or cancellation fees. 6. Release of Liability I hereby release, waive, and discharge RK Beauty Club, its owners, technicians, and staff from any liability, claims, or demands related to treatment outcomes, complications, or reactions that result from my consented procedure, except in cases of proven gross negligence. 7. Data Privacy & Media Release Privacy: I understand that my personal and medical information will be collected, stored, and used in accordance with applicable privacy laws (e.g., PIPA/PIPEDA). Media: Unless I have explicitly indicated otherwise in writing, I grant permission for before/after photos and videos of my treatment to be used for training, educational, and marketing purposes.
Consent
(Required)
I have read, understood, and agree to the Consent & Liability Waiver terms.
Signature
(Required)
Type in Your Full Name
