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Do you have (or getting treated for)
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Please describe condition
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Have you had (in tattoo area)
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If other please explain
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Do you have permanent makeup or implants?
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Have you got any type of skin tan (fake or natural)?
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Do you smoke?
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If yes how much?
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Do you have any allergies?
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If yes what kind?
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Are you currently under a doctor's care?
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Have you taken blood thinners or anti-coagulants in last 3 months?
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Have you taken photosensitizing medication in last 3 months? (anti-depressants, St. Johns Wart etc)
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Other Medications
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Location of tattoo(s)
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Colors in tattoo(s)
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Have you had treatments on your tattoo before?
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When was the last time you had a laser treatment on your tattoo? (Month, Day, Year)
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How old is your tattoo? (Months and years)
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Size of tattoo(s) (estimated measurement in inches)
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Is the tattoo
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Do you have any current or chronic medical illnesses?
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Have you had unprotected sun exposure (including tanning beds and fake tan creams) in the last 4 weeks?
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Do you have history of seizures or any additional known allergies (e.g. Latex, etc)?
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Are you taking medications causing photosensitivity (prescription/non-prescription) eg. St John’s Wort, Anti-coagulants, etc?
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Do you have have a history of keloid & hypertrophic scar formation?
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Do you have any active infections/Immunosuppression?
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Do you have any open lesions in the areas to be treated
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Do you have have Herpes I or II – in the areas to be treated
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Have you used Tretinoin (Retin –A, Renova) within the last 2 weeks
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Have you had Laser Resurfacing within the last 6 months?
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Have you had a Chemical Peel – within the last 4 weeks
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Have you used used Oral isotretinoin/Accutane – within the last 6 months
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Are you diabetic?
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Are you pregnant?
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Have you received the Pre and Post Care Information Sheet. And do you adhere to all these recommendations?
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Do you agree to allow us to use your before and after photos in marketing/training? (No personal information will be shared)
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Have you had any laser treatments performed on your tattoo in the last 60 days?
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How did you hear about us?
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Informed Consent
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Removal Consent
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Kirby-Desai Scoring
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How would you rate your skin in the area to be treated?
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Location
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Colors
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Amount of Ink
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Scarring and Tissue Change
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Tattoo Layers
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Total Points
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