Name *

First Name

Last Name

Address *

Must be located in South Australia or willing to travel to our clinic at own expense

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of birth *

MM

DD

YYYY

Is your tattoo in relation to one of the following: *

Survivor of domestic violence, immigration detention or human trafficking

Ex-gang/bikie member and no longer want to be affiliated with that club or gang in the future

Visible or offensive tattoos tattoos (face, neck, hands, head etc) and can’t secure employment

Racist tattoo/s, would like to remove past beliefs from skin

Child or teenager under 18 - tattooed without their permission

Radiation tattoo marks from cancer treatment or medical marks on skin

Other

Are you currently employed? *

Yes

No

Are you in a position where you are able to afford tattoo removal yourself? *

Yes

No

Have you ever been to prison? or are you currently on home detention? *

Yes

No

Can we use your story and results of your laser removal to promote our Fresh Start Program? *

Yes

No

Terms and conditions *

By filling out this form of consent I understand that this free procedure is only for people in extreme circumstances who need removal to kickstart a fresh start at life. This can include tattoo removal of visible areas (hands, neck and face), offensive tattoos or tattoos that are a harsh reminder of an unfortunate circumstance from the past. I also understand that tattoo removal is a process that requires more than one treatment. If successful, I agree to attend each and every scheduled appointment on time. If an appointment is not kept or cancelled with 48 hours’ notice (with the exception of extreme circumstances), I will be immediately terminated from the program to allow for another committed applicant to take my place.

I agree