Drew Varano, MD

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Tattoo Removal Questionnaire

PLEASE REMEMBER to ALSO SCHEDULE A PHONE CONSULT by clicking the red link or go back on the tattoo removal page AFTER you submit this form

Fields marked with an * are required fields.

*First name: *Last name: MI:

*Address:

*City, State Zip:

*Phone 1: Phone 2:

*eMail:

Occupation:

*Date of birth: (mm/dd/yy)

*Please list the prescriptions you are currently taking:

*Drug allergies:


Please check the SIZE of the tattoo: (1 postage stamp is 1 Sq inch...See our tattoo removal webpage if you are still unclear on how to measure sq inches)
2 Sq inches 4 Sq in 9 sq in (Size of iPhone)16 sq in
25 sq in or larger

Check all that apply:
Pregnant or Nursing Ink Allergy Tattoo older than 20 years
Immunocompromised On Gold products Have permanent cosmetic makeup removed
History of Lupus Recently Tanned Allergy to topical anesthesia (Lidocaine)

Please check your skin type:
Caucasian-burn easily/rarely tan Caucasian-can tan
Olive/Asian/Hispanic/Mediterranean
African American-Light/Middle Eastern African American-dark

Please check all colors that apply to your tattoo:
black yellow red orange dark blue green tan violet

Please check the location of your tattoo:
neck below belt chest/back/abdomen upper leg/upper arm
hand/wrist/forearm/ankle/foot


Was your tattoo made by an amateur? (yes or no)

Was your tattoo done by a professional? (yes or no)

Which best describes your tattoo? One color Multi-color Complex design

Is your tattoo a cover up of an old one? (yes or no)

Have you had any prior laser tattoo removal treatments? (yes or no)

If yes how many prior sessions?

If you have had a prior session, list approximate treatment date:

Do you have any scars over the tattoo? (yes or no)

Pharmacy Phone # (to call in anesthetic cream):

Upload a picture of your tattoo:




 
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