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Return to Services > Tattoo Removal > Tattoo Removal QuestionnaireTattoo 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: *Please check the size of the tattoo:2 Square Inches4 Square Inches9 Square Inches16 Square Inches25 Square Inches or LargerCheck 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:Caucasian-burn easily/rarely tanCaucasian-can tanOlive/Asian/Hispanic/MediterraneanAfrican American-Light/Middle EasternAfrican American-darkPlease check all colors that apply to your tattoo:BlackYellowRedOrangeDark BlueGreenTanVioletWhere is your tattoo located?NeckBelow BeltChest/Back/AbdomenUpper Leg/Upper ArmHand/Wrist/Forearm/Ankle/FootWas your tattoo made by an amateur?YesNoWas your tattoo done by a professional?YesNoWhich best describes your tattoo?One ColorMulit-colorComplex DesignIs your tattoo a cover up of an old one?YesNoHave 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?YesNoPharmacy Phone # (to call in anesthetic cream)Upload a picture of your tattooSubmit
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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