Tattoo Removal Questionnaire

First Name

Middle Initial/label>

Last Name

Street Address

City, State Zip

Phone number

Secondary Phone number

Email address

Date of Birth (mm/dd/yy)

Tattoo Size (optional)
2 Square Inches4 Square Inches9 Square Inches16 Square Inches25 Square Inches or Larger

Please indicate your skin type (optional)
Caucasian-burn easily/rarely tanCaucasian-can tanOlive/Asian/Hispanic/MediterraneanAfrican American-Light/Middle EasternAfrican American-dark

Tattoo location (optional)
NeckBelow BeltChest/Back/AbdomenUpper Leg/Upper ArmHand/Wrist/Forearm/Ankle/Foot

Was your tattoo made by an amateur? (optional)
YesNoNot Sure

Was your tattoo done by a professional? (optional)
YesNoNot Sure

Which best describes your tattoo? (optional)
One ColorMulti-colorComplex Design

Is your tattoo a cover up of an old one? (optional)
YesNo

Have you had prior laser tattoo removal? (optional)
YesNoNot Sure

If yes, how many prior sessions?
12345+

Approximate treatment date

Do you have scars over the tattoo? (optional)
YesNo

Pharmacy Phone #