Return to Services > Tattoo Removal > Tattoo Removal QuestionnairePlease remember to also schedule a phone consult or go back to the tattoo removal page after you submit this form. Fields marked with an * are required fields.First Name*Middle Initial*Last Name*Street Address*City, State Zip*Phone 1*Phone 2*Email*OccupationDate of Birth (mm/dd/yy)*Please list the prescriptions you are currently taking:*Drug allergies:*Tattoo SizePlease check the size of the tattoo:2 Square Inches4 Square Inches9 Square Inches16 Square Inches25 Square Inches or LargerCheck all that apply:Check all that apply:Pregnant or NursingInk AllergyTattoo older than 20 yearsImmunocompromisedOn Gold productsHave permanent cosmetic makeup removedHistory of LupusRecently TannedAllergy to topical anesthesia (Lidocaine)Please indicate your skin type:Please indicate your skin type:Caucasian-burn easily/rarely tanCaucasian-can tanOlive/Asian/Hispanic/MediterraneanAfrican American-Light/Middle EasternAfrican American-darkPlease check all colors that apply to your tattoo:Please check all colors that apply to your tattoo:BlackYellowRedOrangeDark BlueGreenTanVioletWhere is your tattoo located?Where is your tattoo located?NeckBelow BeltChest/Back/AbdomenUpper Leg/Upper ArmHand/Wrist/Forearm/Ankle/FootWas your tattoo made by an amateur?Was your tattoo made by an amateur?YesNoWas your tattoo done by a professional?Was your tattoo done by a professional?YesNoWhich best describes your tattoo?Which best describes your tattoo?One ColorMulit-colorComplex DesignIs your tattoo a cover up of an old one?Is your tattoo a cover up of an old one?YesNoHave you had any prior laser tattoo removal treatments?Have you had any prior laser tattoo removal treatments?YesNoIf yes how many prior sessions?If you have had a prior session, list approximate treatment date:Do you have any scars over the tattoo?Do you have any scars over the tattoo?YesNoPharmacy Phone # (to call in anesthetic cream)Upload a picture of your tattooPrevious Cancel Continue >>
Return to Services > Tattoo Removal > Tattoo Removal Questionnaire
Please check the size of the tattoo:
Check all that apply:
Please indicate your skin type:
Please check all colors that apply to your tattoo:
Where is your tattoo located?
Was your tattoo made by an amateur?
Was your tattoo done by a professional?
Which best describes your tattoo?
Is your tattoo a cover up of an old one?
Have you had any prior laser tattoo removal treatments?
Do you have any scars over the tattoo?
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