Consultation Form | BARE by Marlese

Please complete this form accurately. All information is kept confidential and used only to assess treatment suitability and safety.

Are you a new or existing client?

New clients must complete the consultation and patch test form. Existing clients who have previously completed an approved consultation and patch test can continue to full-price treatment options.

Choose Your Treatment

Treatment Type *

Client Details

Date of Birth *

Contact Number *

Tattoo Information

Approximate age of the tattoo (years) * Location on body * Have you attempted removal before? (Laser, saline, excision or other) If yes, please describe

Tattoo Characteristics

Type of tattoo *

Professional Amateur Cosmetic / PMU Not sure

What colours are in the tattoo? *

Black Blue Green Red Yellow White Multi-colour Not sure

Is the tattoo raised or scarred? *

No Yes

Have you ever had a reaction to your tattoo ink? *

No Yes

If yes, please describe Is this tattoo a cover-up of another tattoo? *

No Yes Not sure

Fitzpatrick Skin Type

This helps us choose safe laser settings and reduce the risk of pigmentation changes.

Your Fitzpatrick skin type

Taking the test will open in a new tab. When you finish, your result will automatically fill here.

Consent & Privacy *

I consent to BARE by Marlese storing and processing my personal and health-related information (including consultation and Fitzpatrick skin type data) to assess treatment suitability and respond to my enquiry. I have read the Privacy Policy. I confirm that I am over 18 years of age. I give informed consent to undergo laser tattoo removal treatment, understanding the risks, healing process, and that results vary.

Please do not submit urgent medical information here. This is for consultation screening only.

Medical screening helps ensure laser treatment is safe and appropriate for your skin and medical history.

Medical History

Do you have or have you ever been diagnosed with any of the following conditions? *

Lupus Psoriasis Vitiligo Eczema / dermatitis Keloid scarring Autoimmune disorder Immunosuppressive medication or therapy (e.g. biologics, chemotherapy, steroid therapy) None of the above

Other (please specify)

Treatment Safety *

Currently pregnant or breastfeeding Recent sun exposure or tanning beds in the last 4 weeks Skin becomes unusually sensitive to sunlight or UV light Moles or suspicious lesions in treatment area Active infection in treatment area Tattoo done within the last 6–8 weeks History of poor wound healing or abnormal scarring None of the above

Recent Skin Preparation *

Have you used fake tan on the treatment area within the last 2 weeks? *

No Yes

Carbon Facial Screening *

Have you had Botox or dermal filler in the treatment area within the last 2 weeks? *

No Yes

Are you currently using exfoliating acids, benzoyl peroxide or prescription acne medication on your face? *

No Yes - e.g. AHA/BHA acids, benzoyl peroxide, retinoids or prescription acne products

Have you had microneedling, laser treatment, a chemical peel or dermabrasion on your face within the last 4 weeks? *

No Yes

Fungal Nail Screening *

Has the nail condition been diagnosed as a fungal infection by a GP, podiatrist or other qualified healthcare professional? *

Yes No Unsure

Are you currently using or taking antifungal medication? *

No Yes - e.g. Terbinafine, Amorolfine/Loceryl or Canesten

If yes, please list the antifungal medication

Viral & Blood-Borne Conditions *

History of cold sores (Herpes Simplex Virus) Hepatitis B Hepatitis C HIV None of the above

Other blood-borne condition (please specify)

Chronic Health Conditions *

Diabetes (Type I or II) Epilepsy or history of seizures Heart condition or pacemaker Bleeding disorder (e.g. haemophilia) History of skin cancer None of the above

Other Chronic Health Conditions (please specify)

Allergies *

Tattoo ink allergy Lidocaine / numbing cream allergy Latex allergy No known allergies

Other allergies (please specify)

Medications & Supplements *

Have you taken Accutane (Isotretinoin) in the last 6 months? *

If yes, treatment may need to be postponed until your practitioner has confirmed it is safe to proceed.

Blood thinners (e.g. Warfarin, Apixaban, Rivaroxaban) Gold therapy (for rheumatoid arthritis) Antibiotics in the last 2 weeks (e.g. Doxycycline, Lymecycline, Minocycline) Steroid medication (e.g. Prednisolone) Prescription skin creams used on the treatment area (e.g. Retin-A, Tretinoin, Adapalene, Hydroquinone) Supplements that may increase bleeding (e.g. Fish Oil/Omega-3, Vitamin E, Ginkgo Biloba) None of the above

List all current prescription medications, over-the-counter medicines, herbs, vitamins and supplements

Lifestyle Factors

Do you currently smoke or vape? *

No Yes - cigarettes Yes - vape Yes - both

If yes: approximate daily use

Smoking and vaping can affect healing and treatment outcomes. For tattoo removal, it may also slow the body’s ability to clear tattoo pigment.

Additional Information

Is there anything else I should know? What outcome are you hoping for?

Photos

Clear photos help us assess treatment suitability before your consultation. Please upload clear, unedited photos taken in good lighting. Avoid filters or beauty enhancements. Include one close-up and one photo showing the surrounding area.

Upload treatment photos (optional)

File upload limits: max 10MB per image, up to 10 images, 20MB total combined. Accepted formats: JPG, PNG, WEBP.

Clinical Photos

Clinical photos (optional)

Clinical photos are used for treatment documentation and monitoring unless separate written consent is provided for marketing or educational purposes.

I consent to clinical photos being taken for treatment monitoring No, I do not consent to photos

Treatment & Aftercare Acknowledgement *

I understand that laser tattoo removal requires proper aftercare, including avoiding sun exposure, not picking blisters or scabs, and allowing appropriate healing time between sessions. I understand that a patch test is required before treatment. Treatment can only proceed after my consultation and patch test have been completed and approved. I understand that laser tattoo removal carries risks including but not limited to blistering, scabbing, swelling, infection, changes in skin pigmentation (hypopigmentation or hyperpigmentation), incomplete removal, and potential scarring. I understand that no guarantee has been made regarding the outcome of treatment and that results vary depending on individual factors including skin type, ink composition, depth, and aftercare compliance. I understand that failure to follow aftercare instructions may increase the risk of adverse effects and may affect treatment results, and I accept responsibility for following all aftercare guidance provided. I confirm that all information provided is accurate and complete to the best of my knowledge. I understand that withholding or providing incorrect information may increase the risk of complications and may invalidate my treatment.

Treatment will only proceed once suitability has been confirmed by the practitioner during consultation.

BARE by Marlese reserves the right to refuse or postpone treatment if it is deemed unsafe or unsuitable based on consultation findings.

Please refer to the aftercare guidance available on the main BARE by Marlese website.

Signed at: Waiting for signature...

Client Signature *

By proceeding, you agree to our booking terms. A minimum of 24 hours’ notice is required for cancellations or rescheduling. Deposits may be non-transferable for late changes.

Consultation & Patch Test Form