top of page
LOGO SIZE.png

LI-FT REMOVAL CONSULTATION FORM

PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY :

The procedure in which our LI-FT solution is used in similar to micro-pigmentation. The difference is we are going to introduce the solution into the upper dermis rather than pigment. The removal formula starts to act as soon as it is applied to the original tattoo. The scab will form over the tattooed area. In the next few days while the skin heals, the ink will be drawn out from the tissue that regenerates into the patchy part of the scab. The scab will start naturally to peel and consequently the undesired ink will be extracted from the skin. After the procedure, the area where the scab has formed should be kept completely dry/no water. The client may apply a vitamin E ointment when the scab has completely formed, and continue to apply while healing - not before the scab is present. 

 

The following information will only be used to assess your removal goals, determine if the treatments is appropriate for your skin condition and to avoid any possible reactions. If you are unsure of any of the following or have any further questions please contact Jordan personally via email on aestheticsjh@gmail.com

​

  • I understand that several treatments may be needed in order to attempt to achieve my desired results however I have not received any guarantees to the quality of the outcome of the process.

  • While the goal of the procedure is to remove all visible signs of the original PMU with minimal to no scarring or other adverse outcomes, I understand that successful and complete removal of the tattoo depends upon many factors such as age of the original tattoo, depth of pigment implantation, type of pigment implanted, whether the original procedure was performed by a professional or unskilled tattoo artist, surface area and body location.

  • I understand that my cooperation in following and complying with all aftercare instructions is crucial to optimising my chances of obtaining the desired outcome.

  • The procedure involves using a sterile tattoo needle paired with the LI-FT removal solution to enter the top layers of the skin, reopening only the areas of skin that has previously been tattooed.

  • The removal process can be painful, but anaesthetic will be applied before treatment numbing the area of skin.

  • It is important, in order to achieve maximum effectiveness of the removal process, for the client to continue with multiple episodes of the removal treatment, waiting for a full 6 weeks in-between. This is because the original pigment will be lifted through and up out of the skin by the solution as the body attempts to rid itself of the hypertonic solution during healing. It is imperative that the site remains dry once all treatments are completed (usually within the 1st 12 hours of initial application in the clinic).

  • I understand that lightening tattoo pigment is difficult, if even possible in some cases. As a result I will not hold my technician or this establishment responsible for any resultant failure to lighten the unwanted pigment.

  • During the healing process, the pigment may become darker before if gets lighter again. This is due to the skins natural defence reaction during the scabbing process. 

  • I agree too before and after photographs, and give my permission to use such photographs for publication and/or for teaching purposes. 

  • There may be immediate or delayed allergic reactions. However, allergic reactions are very rare.

  • A negative allergy test result will not guarantee that you will not have an allergic reaction.

  • Allergic reactions to anaesthetics can occur. 

  • Removal treatments cannot be performed on pregnant or nursing women.

  • Removal treatments cannot be performed on a person under the age of eighteen.

  • Infections can occur if aftercare instructions are not followed correctly.

  • If any sign of infection is seen, the client should consult with their physician.

  • There may be swelling or redness.

  • You may experience minor bleeding.

​

This information is not intended to alarm you; however it is imperative that you are informed of the risks involved.

HAVE YOU RECEIVED CHEMOTHERAPY OR RADIATION IN THE LAST YEAR?
HAVE YOU EVER HAD AN ALLERGIC REACTION TO ANY OF THE FOLLOWING? Required
If a client indicates an allergy to any of the aforementioned ingredients, they may be offered to purchase a new sealed container of LI-FT and consult with their physician for allergy testing. The diagnosis (results of the medically conducted allergy test) is to be provided to the technician and maintained in the client's file. If a client indicates an allergy to any of the ingredients, but cannot or will not pursue a physician conducted allergy test, the use of LI-FT is prohibited.
ALLERGIC TO ANAESTHETICS OR ADRENALINE?
HAVE YOU EVER HAD ANY OF THE FOLLOWING? Required

NUMBNESS

We cannot accept responsibility if the treatment area does not numb. Each individual is different according to the skin type. Some clients have reported that the area is completely numb, while others say they experience some discomfort.

​

PROCEDURE

For all procedures a cream or gel topical anaesthetic is placed over the treatment area for 15 - 20 minutes, then carefully removed prior to treatment. As a result of the treatment, combined with the use of anaesthetic you can expect to experience swelling and redness that could last between 1 and 3 days. You should always follow your post procedure aftercare instructions.

I.   Always burns, never tans

II.  Always burns, sometimes tans

III. Sometimes burns, always tans

IV. Rarely burns, always tans
V.  Brown, moderately pigmented skin

VI. Black skin

For skin types V and VI, you may be at a higher risk for hyper-pigmentation and hypo-pigmentation than other skin types.

GENERAL CONSENT AND PROCEDURE PERMIT

  1. If any unforeseen conditions arise in the course of this procedure(s), calling in his/her judgment in addition to, or different from those now contemplated, I further request and authorise him/her to do whatever he/she seems advisable and necessary in the circumstances.

  2. I understand that an allergy test does not guarantee that I will not have an allergic reaction to the pigment.

  3. I have been informed that the highest standards of hygiene are met, and that sterile disposable needles and pigment containers are used for each individual client, procedure and visit.

  4. I understand and accept that each procedure is a process requiring multiple applications of LI-FT to achieve desirable result, and that 100% success cannot be guaranteed during the first procedure. I understand that this is why I may need to return for multiple removal sessions.

  5. The result of the procedure is determined by the following: medication, skin characteristics, natural skin pigmentation, and post procedure care.

  6. For skin types V and VI only - I understand that I am at a higher risk for hyper-pigmentation and hypo-pigmentation than other skin types. I agree to the risks involved.

  7. Upon completion of the procedure there may be swelling and redness of the skin, which will subside between 1-3 days. In some cases, bruising may occur. You may resume normal activities immediately following the procedure; however, using cosmetics, excessive perspiration and exposure of the sun to the affected area should be limited. See specific post-procedure instructions for details.

  8. To my knowledge I do not have any physical, mental or medial impairment or disability that might affect my well-being as a direct or indirect result of my decision to have the procedure done at this time. I am over the age of 18 years. I am not pregnant. I am not under the influence of drugs or alcohol.

  9. I agree to follow all pre – procedure and post – procedure instructions as provide and explained to me by the technician. I confirm that I have received copies of all the relevant aftercare instructions.

  10. Being of sound mind and body, I hereby release all responsibility. I accept any and all responsibility myself for any consequences that might stem from my decision to have any removal procedures performed by the technician.

  11. For the purpose of the documentation, I also consent to the taking of before and after photographs of said procedures for the record purposes and for use in presentation portfolios.

​

​

I CERTIFY THAT I HAVE READ AND HAVE HAD EXPLAINED TO ME AND FULLY UNDERSTAND THE ABOVE CONSENT AND PROCEDURE PERMIT; THAT THE EXPLANATIONS THEREIN REFERRED TO WHERE MADE AND I ACCEPT FULL RESPONSIBILITY FOR THESE AND OR OTHER COMPLICATIONS WHICH MAY ARRISE OR RESULT DURING OR FOLLOWING THE COSMETIC TATOO PROCEDURE(S) WHICH IS TO BE PERFORMED AT MY REQUEST ACCORDING TO THIS CONSENT AND PROCEDURE PERMIT.

​

I confirm that the above information is correct.

​

Please read and accept the Terms & Conditions.

Thanks for submitting!

NURSE ARLEANA
UNIT 1
93 WHITCHURCH ROAD
SHREWSBURY
SY1 4EQ

THE BODY WORKS CLINIC
31 CHAPEL STREET
SHEPSHED
LOUGHBOROUGH
LEICESTERSHIRE
LE12 9AF

07720247728
AESTHETICSJH@GMAIL.COM

©2020 by Jordan Louise Aesthetics & Training.

PRIVACY POLICY

bottom of page