Tattoo Removal Intake Form
Name
*
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Gender
Male
Female
Trans Male
Trans Female
Non-binary
Prefer not to answer
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Skin and tattoo related
What happens when you stay in the sun for too long?
Red, blistering, peeling
Blister then peel
Burns sometimes then peel
Rarely burn
To what degree do you turn brown?
Hardly or not at all
Light color tan
Reasonably tan
Tan easily
Last exposure to sun, sunlamps or tanning bed:
2 to 3 months ago
1 to 2 months ago
less than a month ago
2 weeks or less
When tanning, do you expose the areas to be treated?
Never
Hardly Ever
Sometimes
Always
Have you ever had skin cancer?
Yes
No
If answer to previous question was yes, where was located?
How old is your tattoo?
Was your tattoo done using a ink gun?
Medical and Health History
Tobacco use
Do you smoke?
Yes
No
If so, type and how many cigarettes a day?
For how long have you been smoking?
Are you a former smoker?
Yes
No
If so, type and how many cigarettes a day?
For how many years did you smoke?
Allergies and medications
Are you taking any daily medications?
Yes
No
Please list the medication,dosage and frequency:
Are you allergic to any medication, food, environmental or other substances? Please list them.
Have you been diagnosed with a chronic disease?(such as diabetes or heart disease)
Yes
No
Disease Diagnosed:
Currently under treatment?
Yes
No
By signing this form I assure I have answered all of the questions at the best of my knowledge.Photographs will be obtained for medical records. If you approve and provided that your name is not revealed and all identifying marks are cropped or removed,these photographs may be used for in-house medical,educational,scientific or advertising purposes.
*
Submit
Should be Empty: