Saline Lightening/Removal Consent

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This form is designed to give the information needed to make an informed decision of whether or not to undergo saline tattoo pigment lightening/removal. If you have any questions, please do not hesitate to ask.
Solace Ink's preferred removal solution is Li-FT®, a safe and highly effective saline based tattoo lightening solution. Li-FT® is an all-natural, hypertonic solution that contains no acids and no chemicals. Li-FT® works in lightening any permanent makeup procedure and smaller body tattoos. Results as well as how many sessions needed will vary depending on the client's skin, type and depth of the pigment and aftercare. Each session is performed every 8 weeks. If you have had an unfortunate permanent makeup procedure and you are unhappy with the results, emergency removal within 48 hours is recommended. The sooner the better! Removal performed within this time frame have the best results and one session may only be needed. Please keep in mind that the goal is to lift as much pigment out of the skin as possible; however, 100% pigment removal is not guaranteed.
By signing you acknowledge, understand, and agree to the following terms:

  • You are 18 years of age or older and you have truthfully represented to your technician that undergoing this procedure is by your choice alone.
  • You are NOT pregnant nor nursing.
  • You are NOT under the influence of alcohol or recreational drugs.
  • You are NOT using blood thinners or medications that may increase bleeding during the procedure.
  • You do NOT have skin conditions such as severe acne, keloid scarring, eczema, facial psoriasis, keratosis, or moles in the procedure area.
  • You do NOT have uncontrolled diabetes, a history of hemophilia/abnormal bleeding, or any medical condition that may cause difficulties during the healing process.
  • You do NOT have freckles, moles or sunburn in the procedure area.
  • You do NOT have any sensitivity to local anesthetics.
  • Infection is very unusual but always possible as a result of the procedure, particularly in the event that you do not follow the proper care following the procedure.
  • Skin treatments such as laser hair removal, botox, plastic surgery or other skin altering procedures may result in adverse changes to the procedure area. These changes may not be correctable. You acknowledge that you have not had a chemical peel, laser peel or applied Retin-A within the last 6 weeks.
  • You understand that the unwanted pigment may not totally be successfully removed.
  • You understand that although rare, in cases where removal is done using needles, permanent scarring can result in an attempt to remove the pigment, as well as possible hyperpigmentation, hypopigmentation, or other damage to the skin, which may be permanent.
  • You will receive aftercare instructions and you agree to follow them.
  • You understand that after he procedure, you will experience reactions typical of wound healing including but not limited to - redness, flaking, itchiness, and slight tingling.
  • You understand there are other options and methods available for pigment lightening/removal. You have decided to move forward with the Saline lightening/removal.
REMOVAL PROCEDURE(Required)
FULL or PARTIAL REMOVAL?(Required)
Do you have any of the following conditions? Check all that apply.(Required)
Emergency Contact(Required)

Consents and Acknowledgements

I understand that photographs and videos will be taken before, during and after each procedure for insurance purposes and will be kept as a part of my client file. I understand that these photographs and videos may also be used for advertising purposes (digital and/or print). By booking and proceeding with my appointment, I agree to have photographs and/or videos with my likeness used for advertising purposes.
YOU AGREE TO ADHERE TO THE FOLLOWING AFTERCARE INSTRUCTIONS:

  • Starting today - Lightly damen a cotton round/cotton ball with the provided solution and apply to the procedure area 3-4 times per day for the next 7 days.
  • After all scabs have naturally fallen off, apply a small amount (grain size) of Vitamin E oil 3-4 times per day for 4 weeks.
  • Do not touch, rub, scratch, or pick the scabs. Doing so may cause scarring and/or hyperpigmentation as well as prevent the saline from removing as much pigment as possible.
  • Until scabbing is complete, no makeup or skincare products should go within 2.5cm of the procedure area.
  • Limit sun and excess water exposure until all flaking is gone.
  • Avoid sleeping on either side of your face until all flaking is gone.

General Medical Aesthetics Release Form / Hold Harmless

I hereby consent to and authorize Vallen J. Cordon to perform the above selected treatment.

Although it is impossible to list every potential risk and complication, I have been informed of the possible benefits, risks, and complications of this treatment. I also recognize there are no guaranteed results and that independent results are dependent upon age, skin condition, and lifestyle and that there is the possibility I may require further treatments of the treated areas to obtain the expected results at an additional cost.

I have read and understand the post-treatment home care instructions. I understand how important it is to follow all instructions given to me for post-treatment care. In the event that I may have additional questions or concerns regarding my treatment or suggested home product/post-treatment care, I will consult the practitioner immediately.

I have also, to the best of my knowledge, given an accurate account of my medical history, including all known allergies, prescription drugs or products I am currently ingesting or using topically. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. I am aware that it is my responsibility to inform the practitioner of my current medical or health conditions and to update this history as needed. I understand that the services offered are not a substitute for medical care and any information provided by the practitioner is for educational purposes only and not diagnostically prescriptive in nature. I understand that the information herein is to aid the practitioner in giving better service and is completely confidential.

I have read and fully understand this agreement and all information detailed in my client consent and waiver forms and information presented at the time of booking. I understand the treatment and accept the risks. All my questions have been answered to my satisfaction and I consent to the terms of this agreement. I do not hold the technician (nor the establishment) responsible for any of my conditions that were present, but not disclosed at the time of this procedure, which may be affected by the treatment performed today. I also release Vallen J. Cordon (the practitioner) and Solace Ink by Dr. Val (the company) of any liability that may arise from this procedure.
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