Saline PMU Removal Consent Form

Lifts unwanted PMU pigments to the surface of the skin by the process of osmosis. Safe and effective treatment for the removal of unwanted PMU procedures.

First Name

Last Name

Phone Number

Address

How did you hear about us?

Are you on any medications or do you have any medical conditions?

Are you allergic or have had a reaction to any type of salt at any time?

The nature and method of the lightening procedure has been explained to me including risks and/or possibility of complications during or following its performance.

I understand there may be a certain amount of discomfort or pain associated with the procedure

Side effects may include: minor and temporary bleeding, bruising, redness or other discoloration and swelling.

Fever blisters may occur on the lips following lip procedures in individuals prone to this problem.

I understand that several treatments may be needed in order to attempt to achieve my desired results.

There are no guarantees to the quality of the outcome of the process.

I understand that the unwanted pigment may not be successfully lightened to the point that it can no longer be seen.

Scarring as hyper-pigmentation or hypo-pigmentation, discoloration or other damage to the skin may occur during this process and may be permanent.

I will not hold my technician liable for any damages that may occur.

Which of the following best describes your skin type?

For skin types V and VI

I understand that I am at a higher risk for hyper-pigmentation & hypo-pigmentation

I agree to the risk involved.

I agree to follow all aftercare instructions provided to me.

I have disclosed all that has been asked of me to the best of my ability

I have had all my questions answered and agree to all conditions and provisions of this document

I accept the risks for having this procedure done

I release my technician from any and all liabilities

Your Signature

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Date