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CONSULTATION FORM  TATTOO/ SPMU REMOVAL

Birthday
Day
Month
Year
Are you pregnant?
Yes
No
Are you breastfeeding?
Yes
No
Have you ever had skin cancer?
Yes
No
Do you have any keloid scars?
Yes
No
Have you ever had vitiligo?
Yes
No
History of herpes simplex (cold sores)?
Yes
No
Any allergic reactions to lidocaine/numbing creams?
Yes
No
Do you have any allergies?
Yes
No
Do you have any thyroid conditions?
Yes
No
Have you had any past major / minor operations?
Yes
No
Do you have a pacemaker?
Yes
No
Do you have diabetes?
Yes
No
Do you have any form of Epilepsy?
Yes
No
Do you have any immune deficiencies? Lupus?
Yes
No
Do you use Retin A or Retinol?
Yes
No
Have you had recently had any sun exposure, sun beds or applied false tan?
Yes
No
Do you currently take any of the following: Blood thinners, Photosensitizing meds, Steroids?
Yes
No
Do you have any of the following: Heart disease, Epilepsy, Skin conditions ?
Yes
No
Do you smoke or consume alcohol regularly?
Yes
No

INFORMED CONSENT – TATTOO / SPMU REMOVAL

Procedure Information


    Laser tattoo removal uses high-intensity laser light to fragment tattoo pigment particles so the body can eliminate them.


    Multiple treatments are typically required depending on tattoo size, age, colors, and skin type.



Authorisation

I hereby authorise Goda Gegužė to assess and treat me for the reduction/removal of an unwanted tattoo and/or semi-permanent makeup (SPMU) using the method and device deemed appropriate for my skin type, pigment/ink, and treatment area.


Treatment Course & Expectations

  • I understand that complete removal cannot be guaranteed and that multiple sessions at appropriate intervals are required.

  • I understand results vary based on factors including ink/pigment composition and depth, colours, skin type, location, age of the tattoo/SPMU, and my adherence to aftercare.

  • Additional maintenance or corrective sessions may be required to obtain optimal results.


Alternatives

Goda Gegužė has explained reasonable alternatives (e.g., no treatment, camouflaging/cover-up, alternative removal methods) and I understand I may choose not to proceed.


Risks & Potential Side Effects


I understand that risks exist with tattoo/SPMU removal and may include, but are not limited to:

  • Common/expected: redness, localised swelling, warmth, tingling, mild to moderate discomfort, frosting/whitening during treatment, pinpoint bleeding, blistering, and/or scabbing/crusting.

  • Pigment/colour changes: temporary or (rarely) permanent hyperpigmentation or hypopigmentation; paradoxical darkening or colour shift of certain cosmetic pigments (e.g., iron oxide/titanium dioxide in brows/lips) to grey/black or other hues.

  • Textural changes & scarring: delayed healing, textural irregularities, atrophic or hypertrophic scarring (rare).

  • Infection: bacterial or, in lip procedures, potential herpes simplex reactivation; I will inform the clinic of any history of cold sores and understand antiviral prophylaxis may be recommended.

  • Allergic reactions: rare local or systemic reactions to released ink/pigment or topical products.

  • Hair effects (eyebrows/treated areas): temporary hair lightening or shedding can occur.

  • Eye safety: for peri-ocular areas, appropriate shielding will be used; failure to comply can risk eye injury.

  • Incomplete clearance: residual “ghosting,” shadowing, or remaining colour may persist

Contraindications & Disclosure

I confirm I have disclosed my full medical history, medications (including photosensitising agents, isotretinoin past 6–12 months, anticoagulants), recent procedures, history of keloids, tendency to hyperpigment, pregnancy/breast-feeding status, and any active infections or dermatologic conditions in the treatment area. I agree to notify the clinic of any changes before subsequent sessions.

Patch Test

I understand that a test spot/patch test may be performed—particularly for SPMU/face areas—to assess pigment response and risk of paradoxical darkening or irritation. Proceeding with full treatment may depend on patch-test results.


Pre- & Post-Treatment Care

I agree to follow the recommendations provided by Goda Gegužė. I understand that:

Before treatment

  • Avoid sun exposure, sunbeds, and self-tan on the treatment area for 30 days prior; use broad-spectrum SPF 30+ daily.

  • Arrive with the area clean and free of makeup/self-tan (for lips/brows, remove cosmetics).

  • Do not wax/thread/depilate or use exfoliants/retinoids/acids on the area for 7 days prior.

  • If prone to cold sores and treating lips, I will discuss antiviral prophylaxis.

After treatment

  • Expect redness/swelling/blistering/crusting; do not pick. Keep the area clean and dry for the first 24–48 hours; then follow wound-care instructions (gentle cleanse, thin occlusive as advised).

  • Avoid excess heat (hot baths, saunas, steam rooms, strenuous exercise) for 48 hours.

  • Avoid swimming/hot tubs and products that may irritate (acids, retinoids, scrubs) until fully healed.

  • No makeup on treated brows/lips until the skin surface has fully healed.

  • Avoid sun exposure, sunbeds, and self-tan on the treated area for 30 days after each session; use SPF 30+ (preferably SPF 50) on exposed areas thereafter.

  • I will contact the clinic immediately if I experience signs of infection, severe pain, unexpected darkening/colour change, or any other concerning reaction.

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.

 for the above mentioned services and understand that there will be no refunds for any performed services.

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TO BE COMPLETED BY THE PRACTICIONER

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