Laser Tattoo Removal Intake and Appointment Form
Patient Information
Full Name
*
First Name
Last Name
Date of birth
*
-
Month
-
Day
Year
Date
Gender
*
Select
Female
Male
Undisclosed
Phone Number
*
-
Area Code
Phone Number
Have you had tattoo removal before?
No
1 Session
2 Session
Other
Tattoo area and measurements
Can I display your treatment / progress photos on our website and / or social media for informational purposes?
Yes
No
Signature
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Laser Tattoo Removal Treatment Questionaire
Have you been on any antibiotics and/or sun sensitive medications in the past two week? This includes any medications that have a contraindications laser treatments.
Yes
No
Have you had any long term sun exposure in the past 4 weeks?
Yes
No
Are you pregnant and/or breastfeeding?
Yes
No
Are you going to have any long term sun exposure in the upcoming weeks?
Yes
No
Have you used any sunless tanner in the past 2 weeks on the area that we will be treating today? It is important that you do not have any sunless tanner residue on your skin because this will lead to a pigment issue.
Yes
No
Have you used any prescription creams on any areas of the body? Retin A, Renova, Tretinion, Avita, Alustra, Adapalene, Avage, Differen, Tazorac, Tazarotene, etc.
Yes
No
Do you have any makeup and/or deodorant and/or lotions on any of the areas we will be treating today?
Yes
No
I agree that I read and fully understand this entire consent form and I am of sound, mind, and fully capable of executing this waiver for myself.
I Agree
I have read and completed the this form in its entirety, and have answered everything to the best of my ability. I have been informed of potentially harmful or negative side effects that may be caused by the laser.
I Agree
By checking this box I agree to and have read and agree to the legal agreement above.
I Agree
Legal Signature
Date
-
Month
-
Day
Year
Date
Treatment information (Laser Tech Fill Out)
Photo
Browse Files
Cancel
of
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Save
Laser Tattoo Removal Treatment Questionaire
Have you been on any antibiotics and/or sun sensitive medications in the past two week? This includes any medications that have a contraindications laser treatments.
Yes
No
Have you had any long term sun exposure in the past 4 weeks?
Yes
No
Are you pregnant and/or breastfeeding?
Yes
No
Are you going to have any long term sun exposure in the upcoming weeks?
Yes
No
Have you used any sunless tanner in the past 2 weeks on the area that we will be treating today? It is important that you do not have any sunless tanner residue on your skin because this will lead to a pigment issue.
Yes
No
Have you used any prescription creams on any areas of the body? Retin A, Renova, Tretinion, Avita, Alustra, Adapalene, Avage, Differen, Tazorac, Tazarotene, etc.
Yes
No
Do you have any makeup and/or deodorant and/or lotions on any of the areas we will be treating today?
Yes
No
I agree that I read and fully understand this entire consent form and I am of sound, mind, and fully capable of executing this waiver for myself.
I Agree
I have read and completed the this form in its entirety, and have answered everything to the best of my ability. I have been informed of potentially harmful or negative side effects that may be caused by the laser.
I Agree
By checking this box I agree to and have read and agree to the legal agreement above.
I Agree
Legal Signature
Date
-
Month
-
Day
Year
Date
Treatment information (Laser Tech Fill Out)
Photo
Browse Files
Cancel
of
Back
Next
Save
Laser Tattoo Removal Treatment Questionaire
Have you been on any antibiotics and/or sun sensitive medications in the past two week? This includes any medications that have a contraindications laser treatments.
Yes
No
Have you had any long term sun exposure in the past 4 weeks?
Yes
No
Are you pregnant and/or breastfeeding?
Yes
No
Are you going to have any long term sun exposure in the upcoming weeks?
Yes
No
Have you used any sunless tanner in the past 2 weeks on the area that we will be treating today? It is important that you do not have any sunless tanner residue on your skin because this will lead to a pigment issue.
Yes
No
Have you used any prescription creams on any areas of the body? Retin A, Renova, Tretinion, Avita, Alustra, Adapalene, Avage, Differen, Tazorac, Tazarotene, etc.
Yes
No
Do you have any makeup and/or deodorant and/or lotions on any of the areas we will be treating today?
Yes
No
I agree that I read and fully understand this entire consent form and I am of sound, mind, and fully capable of executing this waiver for myself.
I Agree
I have read and completed the this form in its entirety, and have answered everything to the best of my ability. I have been informed of potentially harmful or negative side effects that may be caused by the laser.
I Agree
By checking this box I agree to and have read and agree to the legal agreement above.
I Agree
Legal Signature
Date
-
Month
-
Day
Year
Date
Treatment information (Laser Tech Fill Out)
Photo
Browse Files
Cancel
of
Back
Next
Save
Laser Tattoo Removal Treatment Questionaire
Have you been on any antibiotics and/or sun sensitive medications in the past two week? This includes any medications that have a contraindications laser treatments.
Yes
No
Have you had any long term sun exposure in the past 4 weeks?
Yes
No
Are you pregnant and/or breastfeeding?
Yes
No
Are you going to have any long term sun exposure in the upcoming weeks?
Yes
No
Have you used any sunless tanner in the past 2 weeks on the area that we will be treating today? It is important that you do not have any sunless tanner residue on your skin because this will lead to a pigment issue.
Yes
No
Have you used any prescription creams on any areas of the body? Retin A, Renova, Tretinion, Avita, Alustra, Adapalene, Avage, Differen, Tazorac, Tazarotene, etc.
Yes
No
Do you have any makeup and/or deodorant and/or lotions on any of the areas we will be treating today?
Yes
No
I agree that I read and fully understand this entire consent form and I am of sound, mind, and fully capable of executing this waiver for myself.
I Agree
I have read and completed the this form in its entirety, and have answered everything to the best of my ability. I have been informed of potentially harmful or negative side effects that may be caused by the laser.
I Agree
By checking this box I agree to and have read and agree to the legal agreement above.
I Agree
Legal Signature
Date
-
Month
-
Day
Year
Date
Treatment information (Laser Tech Fill Out)
Photo
Browse Files
Cancel
of
Back
Next
Save
Laser Tattoo Removal Treatment Questionaire
Have you been on any antibiotics and/or sun sensitive medications in the past two week? This includes any medications that have a contraindications laser treatments.
Yes
No
Have you had any long term sun exposure in the past 4 weeks?
Yes
No
Are you pregnant and/or breastfeeding?
Yes
No
Are you going to have any long term sun exposure in the upcoming weeks?
Yes
No
Have you used any sunless tanner in the past 2 weeks on the area that we will be treating today? It is important that you do not have any sunless tanner residue on your skin because this will lead to a pigment issue.
Yes
No
Have you used any prescription creams on any areas of the body? Retin A, Renova, Tretinion, Avita, Alustra, Adapalene, Avage, Differen, Tazorac, Tazarotene, etc.
Yes
No
Do you have any makeup and/or deodorant and/or lotions on any of the areas we will be treating today?
Yes
No
I agree that I read and fully understand this entire consent form and I am of sound, mind, and fully capable of executing this waiver for myself.
I Agree
I have read and completed the this form in its entirety, and have answered everything to the best of my ability. I have been informed of potentially harmful or negative side effects that may be caused by the laser.
I Agree
By checking this box I agree to and have read and agree to the legal agreement above.
I Agree
Legal Signature
Date
-
Month
-
Day
Year
Date
Treatment information (Laser Tech Fill Out)
Photo
Browse Files
Cancel
of
Back
Next
Save
Laser Tattoo Removal Treatment Questionaire
Have you been on any antibiotics and/or sun sensitive medications in the past two week? This includes any medications that have a contraindications laser treatments.
Yes
No
Have you had any long term sun exposure in the past 4 weeks?
Yes
No
Are you pregnant and/or breastfeeding?
Yes
No
Are you going to have any long term sun exposure in the upcoming weeks?
Yes
No
Have you used any sunless tanner in the past 2 weeks on the area that we will be treating today? It is important that you do not have any sunless tanner residue on your skin because this will lead to a pigment issue.
Yes
No
Have you used any prescription creams on any areas of the body? Retin A, Renova, Tretinion, Avita, Alustra, Adapalene, Avage, Differen, Tazorac, Tazarotene, etc.
Yes
No
Do you have any makeup and/or deodorant and/or lotions on any of the areas we will be treating today?
Yes
No
I agree that I read and fully understand this entire consent form and I am of sound, mind, and fully capable of executing this waiver for myself.
I Agree
I have read and completed the this form in its entirety, and have answered everything to the best of my ability. I have been informed of potentially harmful or negative side effects that may be caused by the laser.
I Agree
By checking this box I agree to and have read and agree to the legal agreement above.
I Agree
Legal Signature
Date
-
Month
-
Day
Year
Date
Treatment information (Laser Tech Fill Out)
Photo
Browse Files
Cancel
of
Back
Next
Save
Laser Tattoo Removal Treatment Questionaire
Have you been on any antibiotics and/or sun sensitive medications in the past two week? This includes any medications that have a contraindications laser treatments.
Yes
No
Have you had any long term sun exposure in the past 4 weeks?
Yes
No
Are you pregnant and/or breastfeeding?
Yes
No
Are you going to have any long term sun exposure in the upcoming weeks?
Yes
No
Have you used any sunless tanner in the past 2 weeks on the area that we will be treating today? It is important that you do not have any sunless tanner residue on your skin because this will lead to a pigment issue.
Yes
No
Have you used any prescription creams on any areas of the body? Retin A, Renova, Tretinion, Avita, Alustra, Adapalene, Avage, Differen, Tazorac, Tazarotene, etc.
Yes
No
Do you have any makeup and/or deodorant and/or lotions on any of the areas we will be treating today?
Yes
No
I agree that I read and fully understand this entire consent form and I am of sound, mind, and fully capable of executing this waiver for myself.
I Agree
I have read and completed the this form in its entirety, and have answered everything to the best of my ability. I have been informed of potentially harmful or negative side effects that may be caused by the laser.
I Agree
By checking this box I agree to and have read and agree to the legal agreement above.
I Agree
Legal Signature
Date
-
Month
-
Day
Year
Date
Treatment information (Laser Tech Fill Out)
Photo
Browse Files
Cancel
of
Back
Next
Save
Laser Tattoo Removal Treatment Questionaire
Have you been on any antibiotics and/or sun sensitive medications in the past two week? This includes any medications that have a contraindications laser treatments.
Yes
No
Have you had any long term sun exposure in the past 4 weeks?
Yes
No
Are you pregnant and/or breastfeeding?
Yes
No
Are you going to have any long term sun exposure in the upcoming weeks?
Yes
No
Have you used any sunless tanner in the past 2 weeks on the area that we will be treating today? It is important that you do not have any sunless tanner residue on your skin because this will lead to a pigment issue.
Yes
No
Have you used any prescription creams on any areas of the body? Retin A, Renova, Tretinion, Avita, Alustra, Adapalene, Avage, Differen, Tazorac, Tazarotene, etc.
Yes
No
Do you have any makeup and/or deodorant and/or lotions on any of the areas we will be treating today?
Yes
No
I agree that I read and fully understand this entire consent form and I am of sound, mind, and fully capable of executing this waiver for myself.
I Agree
I have read and completed the this form in its entirety, and have answered everything to the best of my ability. I have been informed of potentially harmful or negative side effects that may be caused by the laser.
I Agree
By checking this box I agree to and have read and agree to the legal agreement above.
I Agree
Legal Signature
Date
-
Month
-
Day
Year
Date
Treatment information (Laser Tech Fill Out)
Photo
Browse Files
Cancel
of
Save
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