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UNDO® Removal Treatment

"My goal is to help you gain back confidence.” Jacky.


INFORMED CONSENT FORM

Although every precaution will be taken to ensure your safety and well-being before, during, and after your treatment/procedure, please be aware of the following information and possible risks and indicate that you fully understand what to expect. Please initial:

I hereby consent to and authorize the technician/esthetician to perform the following treatment/procedure: UNDO® Removal Treatment 


I voluntarily agree to undergo this treatment/procedure after the nature and purpose of this treatment/procedure has been explained to me, along with the risks and hazards involved. 


Although it is impossible to list every potential risk and complication, I have been informed of possible benefits, risks, and complications. 


I understand that it is imperative to my health and safety that I disclose all of the information requested in the Client Consultation/Health History form. I have cited all conditions and circumstances regarding my health history, allergies, and medications, supplements, or prescriptions being taken (orally and/or topically), and any past reactions to products or medications. 


I understand that no specific guarantees of the results can or have been made and that there is the possibility I may require additional treatments/procedures to obtain the expected results at an additional cost. 


I have read and understand all pre-treatment, post-treatment, and home care instructions. I understand the importance of following all instructions given to me. In the event that I have additional questions or concerns regarding my treatment or post-treatment care, I will consult the technician/esthetician immediately. I understand that if I choose to consult a physician, I do so at my own expense. 


I consent to “before-and-after” photographs for the purpose of documentation, potential advertising, and promotional purposes. 


I understand that if I have any concerns, I will address these with my technician/esthetician. I give permission to my technician/esthetician to perform the above treatment/procedure we have discussed and will hold him/her/them and his/her/their staff harmless and nameless from any liability that may result from this treatment/procedure. I understand my technician/esthetician will take every precaution to minimize or eliminate negative reactions as much as possible. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read and fully understand the above paragraphs and that I have been provided sufficient opportunity for discussion and to have any questions answered. I understand the procedure and accept the risks. I do not hold the technician/esthetician, whose signature appears below, responsible for any of my conditions that were present but not disclosed at the time of this procedure that may be affected by the treatment performed today. 

Client Signature:

Date: August 2, 2025

Products used UNDO® Removal: Estetique International® has developed the ultimate range of products for individuals interested in removing or lightening permanent makeup, scalp micropigmentation, and small-medium sized body tattoos. This company is passionate about the removal of products contain safe and natural ingredients that are free from saline and harsh acids and are therefore gentle on your skin. Estetique International® has spent extensive research and testing for developing our products. Under clinical tests, the products have been proven successful in all of the trials. 

The nature, method, and all risks of the proposed tattoo ink lightening or removal procedure has been explained to me. I was given full opportunity to ask any questions.

I Agree

I understand that there may be a certain amount of discomfort or pain associated with the procedure. Additional, rarely occurring, adverse side-effects may include but are not limited to lightning or darkening, scarring, and/or infection of the skin. I understand that in the event of any extreme swelling, tenderness, and possible infection I must seek medical attention by calling my primary care physician.

I Agree

I clearly understand ALL THE RISKS involved and the likelihood of any adverse reactions to the procedure. My technician, Jacqueline Soto owner of Beauty Realm LLC, will work with me to help achieve the best results possible. 

I Agree

I understand there are other options, including LASER, available for removal of ink or pigment. I have decided to decline those methods.  

I Agree

I understand that several treatments may be needed to achieve my desired result. However, I understand there is no guarantee or assurance as to the ultimate outcome or result of this procedure. I understand that Beauty Realm LLC has a NO REFUND POLICY. 

I Agree

I will not hold Beauty Realm LLC or any owners, employees, or independent contractors of Beauty Realm LLC liable for any damages that may occur to my person. 

I Agree

I understand that the complete removal of tattoos is difficult. As a result, I will not hold Jacqueline Soto or Beauty Realm LLC responsible for any resultant failure to lighten or remove completely the unwanted ink. 

I Agree

I agree to follow the ‘Aftercare Instructions’ provided to me while healing. I agree that any complications resulting from my negligence are totally my responsibility. 

I Agree

I understand that I will be given written instructions (printed or virtual) for post- procedure care and follow-up. 

I Agree

I agree to submit to before and after photographs and I give my permission to use such photographs for publication and/or for teaching purposes only upon signing this form. 

I Agree
 

I understand all the information listed above and have had my questions concerning the non-laser tattoo removal process answered and I agree to all conditions and provisions of this document as evidenced by my signature below. I accept the risks of having this procedure done and I voluntarily request that the tattoo lightening and removal procedure(s) are to be performed on me: 

Please sign: 

Today's date: August 2, 2025


POLICY CONSENT

Rescheduling & Cancellations

You are responsible for rescheduling or canceling your appointment via the booking app link sent to you by text. If you are experiencing technical issues, please text Jacky at 719-297-1447.

No charges for rescheduling if done 48 hours prior to your appointment time. 


Children Policy

To fully enjoy your experience, please leave children at home unless they are being serviced. Enjoy your self-care! 


Consent Forms

After your booking is confirmed, please visit the main page of my website and click the menu bar (top right-hand corner). Select the drop-down menu, proceed to select the consent form for your treatment. Forms must be completed at least 6-8 hours prior to your treatment time. 


Arrival Instructions

Upon arrival, find Jacky’s doorbell by the reception desk. Please have a seat and wait for your name to be called. You are welcome to use the restrooms within the facility. 


Conduct Policy

Disrespectful behavior will not be tolerated. You may be dropped as a future client if Jacky feels uncomfortable or unsafe. 


Tardiness

Appointments are subject to rescheduling and additional fees if you are more than 10 minutes late. 


Cancellation Fees

  • Late cancellation (less than 48 hours): 50% of service total
  • Same-day rescheduling/cancellation: 50% of service total
  • No-show/no-call: 100% of service total

No-shows or no-calls may result in being dropped as a future client. 


Refunds & Satisfaction Policy

Please note that no refunds will be issued for services rendered. However, your satisfaction is very important to me. If you are dissatisfied with your service, please contact me directly as soon as possible. I will work with you to address your concerns and ensure you are comfortable with your results. I am committed to providing an excellent experience and will make every effort to resolve any issues.


Retail Item Policy

All retail sales are final and non-refundable. However, if you are not completely satisfied with your purchase, I am happy to offer an even exchange for another product of equal value. Please contact Jacky within 7 days of purchase to initiate the exchange. Items must be unused, unopened, and in original condition to qualify for an exchange. 



Beauty Realm LLC
(719) 297-1447

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Additional Information
Technician/Esthetician Performing Procedure:*
ID of Client or of Parent or Guardian (if Client is underage)
  
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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.


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.
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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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