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Waiver for those receiving our laser removal services

 

 

Rules of our Studio

  1. Absolutely no food or drink outside of the lobby. Please do not ask.
  2. Unless your child has an appointment for an ear piercing, children are not allowed anywhere in the studio.
  3. Do not go into service rooms unless you are invited.
  4. Each customer may have ONE friend joining them in a service area.
  5. A valid government issued I.D. must be presented before all services. No I.D. No service..
  6. We reserve the right to refuse service to anyone.
  7. If you need to smoke please do not smoke outside our doors.
  8. No screaming or yelling.
  9. Please respect the studio and it's staff.
  10. Do not remove bandages from tattoos or change or remove body jewelry in the studio unless assisted by staff members.

Industry Standards Regarding Tipping

Tipping is not required to receive any of our services. We do not believe in adding mandatory gratuity. However it is customary in our industry to tip your staff. The recommended amount to tip your artist is 20% of your service.

Taxes on services and surcharges

There is no sales tax in Florida for services. However there is a 7.5% Environmental Health surcharge on all services.

Notice of Professional Responsibility

I understand that if I do not remain still during my laser session or notify us of excessive discomfort our professional obligation may require us to terminate the session for the day.

Multiple sessions will most likely be necessary to fully remove pigmentation. 

I Agree
April 25, 2024

Waiver and Liability Release

To my knowledge I do not have any mental or medical impairment or disability which might affect my well being as a direct or indirect result of my decision to have any procedure done at this time.

I consent to and authorize East Coast Worldwide Studios Inc to perform multiple treatments, laser procedures, and related services on me. The procedure planned uses laser technology for the removal of tattoos.

I agree for myself, my heirs, assigns and legal representatives to hold harmless from all damages, actions, causes of action, claim judgements, costs of litigations, attorney's fees and all other costs and expenses which might arise from my decision to have any tattoo service done by East Coast Worldwide Studios Inc.

I agree to pay for any and all damages and injuries to any persons and property belonging to East Coast Worldwide Studios Inc. or any other person whom they may become liable contractually or by operation of law, caused by or resulting from my decision to have any tattoo work done by East Coast Worldwide Studios Inc.

I hereby grant irrevocable authorization for use of any reproduction by East Coast Worldwide Studios Inc., and and all photographs or videos which are taken of this day of me, negative or positive proof which will be hereby attached for any purposes whatsoever, without further compensation to me. All negatives, together with the prints, video, or live internet stream shall become and remain the property of East Coast Worldwide Studios Inc., soley and completely.

I swear and affirm and agree that the information is true and correct. I have been provided with information describing the tattoo procedure to be performed and instructions on aftercare. I have been made aware that if I have any signs or symptons of infections, swelling, pain, redness, warmth, fever, unusual discharge, or odor to contact my physician. I also acknowledge it is also my responsibility to take care of my new tattoo according to the instructions provided both verbally and in writing.

I agree that if my body displays any signs or symptons of infections, swelling, pain, redness, warmth, fever, unusual discharge, or odor the session will be ended by the staff member as part of his/her professional responsibility.

As a patient you have the right to be informed about your treatment so that you may make the decision whether to proceed for laser tattoo removal or decline after knowing the risks involved. This disclosure is to help to inform you prior to your consent for treatment about the risks, side effects and possible complications related to laser tattoo removal.


The following problems may occur with the laser tattoo removal process:

The possible risks of the procedure include but are not limited to pain, swelling, redness, bruising, blistering, crusting/scab formation, ingrown hairs, infection, and unforeseen complications which can last up to many months, years, or permanently.

There is a risk of scarring. Scarring happens but is uncommon. Scarring can be permanent.

Short-term effects may include reddening, mild burning, temporary bruising, or blistering.  A brownish/red darkening of the skin (known as hyperpigmention) or lightening of the skin (known as hypopigmentation) may occur at times up to 3-6 months, years, or permanently following treatment. Loss of freckles or pigmented lesions can occur. 

Textural changes in the skin can occur and can be permanent. 

Infection: Although infection following treatment is unusual, bacterial, fungal, and viral infections can occur. Should any type of skin infection occur, additional treatments, or medical antibiotics may be necessary.

Bleeding: Pinpoint bleeding is rare but can occur following treatment procedures. Please follow the basic after-care instructions to prevent the risk of infection.

Allergic Reactions: Upon dissemination, the pigments can induce a severe allergic reaction that can occur with each successive treatment. This may occur if you are allergic to the ink in your tattoo, or to the topical ointments (Neosporin or similar) applied after the laser procedure. 

I understand that exposure of my eyes to light could harm my vision. I must keep the eye protection goggles on at all times.

Compliance with the aftercare guidelines is crucial for healing and the prevention of scarring and skin tone changes.

Occasionally, unforeseen mechanical problems may occur and your appointment will need to be rescheduled. We will make every effort to notify you prior to your arrival to the office. Please be understanding if we cause you any inconvenience. 

We occasionally may use photographs taken before or after treatments in order to assess, promote, train, or improve our services. These will be used anonymously and only include the treated area and not associated with any particular patient.

 

ACKNOWLEDGMENT:

My questions regarding the procedure have been answered satisfactorily. I understand the procedure and accept the risks. I hereby release East Coast Worldwide Studios, Inc, its staff, and medical director from all liabilities associated with the above indicated procedure.

 

April 25, 2024

 

 

Please remove all sharp objects from your person before laying on our equipment to prevent holes or tears. Holes or tears render the furniture uncleanable and you will be responsible for cost of repair or replacement

I Agree

Who is getting laser removal?
AdultMinor
Continue
First Client's Name

First Name*

Middle Name

Last Name*

Phone*
First Client's Date of Birth*
First Client's Dr. Contact Information
Which Doctor would you like us to call in case of emergency? (We will call 911 and give this information to them)*
Ascension St Vincent's Southside - 4201 Belfort Rd, Jacksonville FL 32217 904-296-3700
Other

If Other, What is your doctors name?

Doctor's Address

Doctor's Phone Number
First Client's Signature*
Client's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*
Check to receive information, news, and discounts by e-mail.
A signed copy of this waiver will be sent to the email address you provide.
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Parent or Guardian's Driver's License / ID Card

Driver's License / ID Card Number*

Issuing State*
Medical History (selecting yes does not automatically disqualify you)
Are you pregnant?*
No
Yes
Are you under the influence of any substance?*
No
Yes

Please list any allergies (If none leave blank)
How did you hear about us?
How did you hear about us?*

If "other" please tell us how!! If "friend" please tell us who!!
Description of what is being removed.

Brief description of your tattoo *

Location of tattoo on your body *

Name of Staff member servicing you today. *
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above. A notarized affidavit is required. If your names do not match on your ID's then additional paperwork will be necessary.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Dr. Contact Information
Which Doctor would you like us to call in case of emergency? (We will call 911 and give this information to them)*
Ascension St Vincent's Southside - 4201 Belfort Rd, Jacksonville FL 32217 904-296-3700
Other

If Other, What is your doctors name?

Doctor's Address

Doctor's Phone Number
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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