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MEDICAL HISTORY QUESTIONNAIRE, INFORMED CONSENT & TEST PATCH CONSENT

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Ongoing Consent, Procedure consent AND Waiver:  

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I declare, that I have listed as clearly as possible any medical conditions or medications & information as requested that apply to me.

I release Out Of Space, Alexander Dalitz, all his staff, all team persons, all subcontractors, all trainee license holders undergoing supervision, from every Liability at any time, now, or at all in the future for unwanted outcomes which may occur to me whilst I freely request to have the procedure.

EXPLANATION OF RISKS & COMPLICATIONS all Light-based Treatments:

All light-based treatments carry risks. Outcomes out of our control may include scarring, skin pigment changes, texture changes, and infection. I understand that the aftercare of my treatment is my own responsibility and Out of Space has explained clearly, the consequences of poor aftercare and the correct aftercare procedures and guidelines.

Out Of Space is unable to advise whether a treatment will have any unwanted side effects or other unknown outcomes. Every client will have a Test Patch on their area to be treated. The risks and complications have been clearly explained to me. I understand and take full responsibility for all risks and outcomes outside of clinicians control associated with Laser tattoo removal. I freely request to have the procedure.

COMPLICATIONS FROM UNKNOWN INK COMPONENTS IN YOUR TATTOO:  

I have no idea about the ink/product that was placed into my skin when I had the original tattoo applied.  In the event that a negative outcome occurs or any other unwanted result or unknown outcome occurs either from the Test Patch or procedural treatment; I take full responsibility and do not hold Out Of Spaces or any of its team persons responsible. All my questions have been answered to my satisfaction.  I consent and agree to all the terms within the CONSENT & WAIVER and understand that all procedures are test patched prior to treatment. I freely request to have the procedure.

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Person Under 18,

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IF the client is a Mum-To-Be, or Mums breast-feeding she cannot be treated

Will Not Treat Sunburnt Or Fake Tanned Skin

 
 
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If you have answered YES to drug use, you may not be treated here today.

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If YES, you may not be treated at Out Of Space Tattoo Removal. You are best to visit a specialist to have an opinion and a treatment plan from them.


Consent for PreLaze / Numbing Cream Application

I, name listed as the above, am over the age of 18 or with my parent or guardian and desire to receive PreLaze. A pain, scaring and blister reduction used with laser tattoo removal treatment. The general nature of this procedure(s) to be performed has been explained to me, and I fully understand.

I have been informed of the nature, risks and possible complications and consequences of this procedure(s). I understand the procedure carries with it known and unknown complications and consequences associated with this type of procedure(s), including but not limited to: Infection, allergic reaction, scarring, keloid, pigment or colour change.

I hereby consent to the above procedure being done on me and in consideration of their doing so, I hereby and forever discharge Out of Space Tattoo Removal, all its clinicians and employees of all claims, demands, damages, actions and cause of action arising out of the performance of the said treatment procedure(s).

Being of sound mind and body, I hereby release any and all persons representing Out of Space Tattoo Removal from all responsibility. I accept all responsibility, myself for any consequences that might stem from my decision to have any procedure(s) related work done by Out of Space Tattoo Removal. I agree that these waivers also pertain to and are designed to protect all establishments where Out of Space Tattoo Removal conducts business. I accept the treatment procedure and payment terms in and related to this contract.

I understand that the taking of before and after photographs of any and all procedures preformed by Out of Space Tattoo Removal are a condition of such procedure(s), as such I consent/authorize OOSTR to use photos for any promotional use which is exposed to the public. I certify I have read the above paragraphs and have had explained to my understanding this consent and procedure(s) permit. I accept full responsibility for the decision to have this treatment procedure(s) done.

I have brought my own topical numbing agent to use with PreLaze and am aware of all the potential risks that go with using it. I have applied the numbing cream myself. I understand the risks and accept all consequences there after.

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Person Under 18,

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