Laser Consent – C&D Digital Signatures

Laser Consent Form

Date of Treatment (Select)(Required)

Name(Required)

First Last

Pronouns (optional)

Pronouns (other)

Email(Required)

Telephone(Required)

Address(Required)

Street Address Address Line 2 Town / City Post Code Country

Date of Birth:(Required)

Please confirm the following:

I understand that the technician will be in close physical contact with me during the procedure.(Required)

* I understand that the technician will be in close physical contact with me during the procedure.

I am not under the influence of alcohol or drugs.(Required)

* I am not under the influence of alcohol or drugs.

My eyes will be covered with laser-specific safety eyewear or an opaque material to protect them from the intense light. I will not attempt to remove the eye protection during the treatment.(Required)

* My eyes will be covered with laser-specific safety eyewear or an opaque material to protect them from the intense light. I will not attempt to remove the eye protection during the treatment.

Whilst every effort is made to ensure side effects are minimised, the process of laser tattoo removal does involve some risks and possible side effects. I understand that as a result of having a laser procedure I may experience side effects including, but not limited to: Swelling, Bruising, Itching, Soreness, Blisters, Scabbing / Crusting, Skin colour and / or Textural Changes, Discolouration and Scarring.(Required)

* Whilst every effort is made to ensure side effects are minimised, the process of laser tattoo removal does involve some risks and possible side effects. I understand that as a result of having a laser procedure I may experience side effects including, but not limited to: Swelling, Bruising, Itching, Soreness, Blisters, Scabbing / Crusting, Skin colour and / or Textural Changes, Discolouration and Scarring.

On leaving the studio I understand that the aftercare of my lasered tattoo is my responsibility, and I will follow the shops advice. It is important in order to minimise the chance of incomplete healing, skin textural changes or scarring. Sun avoidance may be recommended. Tanning should be avoided.(Required)

* On leaving the studio I understand that the aftercare of my lasered tattoo is my responsibility, and I will follow the shops advice. It is important in order to minimise the chance of incomplete healing, skin textural changes or scarring. Sun avoidance may be recommended. Tanning should be avoided.

Whilst we make every effort to give you an informed idea of how many sessions your removal will take there are many factors that affect the rate of removal, some of which are beyond our control. Two tattoos that look the same can end up taking a different number of sessions. For people looking for full removal we offer a 'full removal' package where we will continue to treat your tattoo/s until all removable ink is cleared. In some circumstances it may not be possible to fully remove a tattoo.(Required)

* Whilst we make every effort to give you an informed idea of how many sessions your removal will take there are many factors that affect the rate of removal, some of which are beyond our control. Two tattoos that look the same can end up taking a different number of sessions. For people looking for full removal we offer a 'full removal' package where we will continue to treat your tattoo/s until all removable ink is cleared. In some circumstances it may not be possible to fully remove a tattoo.

I consent to pictures being taken to record the progress of my removal.

I consent to pictures being taken for use by the shop on their website and other digital outlets (if you have any questions or concerns about how your pictures will be used then please let us know).

To your knowledge, do you suffer from any of the following conditions?

Active skin infection / disease including: cold sores, impetigo, scabies, fungal, shingles, eczema, psoriasis and tumours (e.g. basal cell, basal cell carcinoma, melanoma).(Required)

Yes

Acne - Pustular / Cystic(Required)

Yes

Autoimmune collagen / vascular diseases e.g. SLE / Lupus, PAN(Required)

Yes

Bleeding disorders and anti-coagulant therapy (e.g. Heparin, Warfarin, Aspirin) and Clotting disorders(Required)

Yes

Blood borne infections e.g. hepatitis A, B or C, or HIV / Aids(Required)

Yes

Bruised or mottled skin(Required)

Yes

Current or history of cancer(Required)

Yes

Diabetes(Required)

Yes

Keloid scarring(Required)

Yes

Scarring - atrophic, hypertrophic and general scarring(Required)

Yes

Pacemaker / Angina / Severe cardiovascular problems(Required)

Yes

Photosensitive epilepsy(Required)

Yes

Known photosensitivity e.g. porphyria or Xeroderma(Required)

Yes

Pigmented lesions, skin lesions or blemishes - lentigines, age spots, moles, birthmarks(Required)

Yes

Pigmentation disorders - Melasma / Chloasma / Vitiligo / hypo/hyperpigmentation(Required)

Yes

Polycystic Ovarian Syndrome (PCOS)(Required)

Yes

Raynaud's disease (severe)(Required)

Yes

Rosacea(Required)

Yes

Varicose veins(Required)

Yes

High / low blood pressure(Required)

Yes

Do you have a latex allergy?(Required)

Yes

Have you used Roaccutane / Tretinoin or oral Retin A within the last 6 months?(Required)

Yes

Has there been recent UV exposure of the area to be treated where the skin is recovering from the inflammatory effects of sun, tanning beds, etc?(Required)

Yes

Are you pregnant or breastfeeding?(Required)

Yes

Have you had any recent major / minor operations?(Required)

Yes

Have you had treatments in the area in the last 6 weeks e.g. resurfacing, chemical peels, epilation, botox?(Required)

Yes

Do you have any foreign objects under the skin in the treatment area e.g. metal implants, fillers?(Required)

Yes

Do you have any cuts or wounds in the treatment area?(Required)

Yes

Detail any other medical conditions:

List any allergies:

List any medication:

Notes:

Please leave for the Cloak & Dagger team to add any relevant information.

I have answered these questions correctly to the best of my knowledge.(Required)

* I have answered these questions correctly to the best of my knowledge.

I have been given the opportunity to ask questions about the procedure. My questions have been answered, and I understand the information given to me.(Required)

* I have been given the opportunity to ask questions about the procedure. My questions have been answered, and I understand the information given to me.

Market Research (optional):

How did you hear about Cloak and Dagger?

Why did you choose Cloak and Dagger?

I understand that:

Digital Legal Consent(Required)

Consumer Disclosure Regarding Conducting Business Electronically, Signing Documents Electronically, and Receiving Electronic Notices and Disclosures

Please read the information below, carefully, as it concerns your rights. eSignatures are an efficient way to execute an agreement with the same legal force and effect of a handwritten or "wet ink" signature. By signing this document you are agreeing that you have reviewed this Consumer Disclosure and consent and intend to transact business electronically; to use electronic signatures instead of wet ink signatures and paper documents, and to receive notices and disclosures electronically.

You are not required to sign documents electronically or to receive notices and disclosures electronically. If you prefer not to transact business electronically, you may request paper copies from the "sending party" and withdraw your consent at any time, as described below.

Scope of Consent
By utilising this Service, you agree to receive electronic signature documents with all related and identified documents, notices, and disclosures provided during your relationship with the "sending party." You may withdraw your consent, at any time, by following the procedures outlined below.

Paper Copies
You are not required to sign documents electronically, or receive notices or disclosures electronically, and may request paper copies of documents or disclosures, if you prefer. You also have the ability to download and print any signed or unsigned documents sent to you through the electronic signature service. We may also email you a copy of all documents you sign using the electronic signature service. If you wish to receive paper copies instead of electronic documents you may close this web browser and request paper copies from the "sending party" by following the procedures outlined below. The "sending party" may apply a charge for additional expenses incurred by printing and mailing paper copies.

Withdrawal of Consent
You may withdraw your consent to receive electronic documents, notices or disclosures at any time. In order to withdraw consent you must notify the "sending party" that you wish to withdraw your consent to transact business electronically and to provide your future documents, notices, and disclosures in paper format. If at any time, after withdrawing your consent you choose to use our electronic signature system your use of this Service will, once again, evidence your consent to receive documents, notices, and disclosures, electronically. You may withdraw your consent to receive electronic notices and disclosures or execute an electronic signature by following the procedures described below.

Withdrawing your consent, requesting a paper copy, or updating your contact information
You always have the ability to download and print any documents sent to you through our electronic signature system. To withdraw your consent to conduct business electronically, sign documents electronically, and receive documents, notices, or disclosures electronically, please contact the "sending party" directly; by telephone, by email (sent to the "sending party" with any of the topics outlined below stated in the subject line of your email) or by postal mail to their mailing address specified to receive such notices.

"Withdrawal of Consent To Transact Business Electronically" To allow the "sending party" to identify and facilitate your withdrawal of consent to transact business electronically, please provide your name, email address, the date on which you are withdrawing your consent, your telephone number and mailing address.

"Requesting A Paper Copy" To allow the "sending party" to identify you to provide a paper copy of the document requiring your signature, the notice, or disclosure, please provide the sending party with your name, email address, mailing address, telephone number, and name of the document of which you are requesting a paper copy .

"Update Your Contact Information" To allow the "sending party" to identify you in order to update your contact information, please provide them with your name, email address, mailing address, and telephone number.

The "sending party" will inform you of any fees related to costs for printing and mailing paper copies or your withdrawal consent to transact business electronically.

I agree to the terms and conditions.

Signed(Required)

Admin Verification(Required)

Please hand the tablet/laptop to the Cloak & Dagger team member for them to check all your details before finalising the form.