Fitzpatrick Skin Type Form
Prospective Client Name
First Name
Last Name
My ethnic origin is close to: (check one)
Very fair(Celtic and Scandinavian)
Fair-skinned Caucasian with light hair and light eyes
Pale-skinned Caucasian with dark hair and dark eyes
Olive-skinned(Mediterranean, some Asian, some Hispanic)
Dark-skinned(Middle easten, Hispanic, Asians, some Africans)
My eye Colour is:
Light Blue
Blue/Green
Green/Grey
Hazel/light Brown
Brown
My natural hair colour at age 18 was:
Red
Blonde
Light Brown
Dark Brown
Black
The colour of my skin that is not normally exposed to the sun is:
Pink to reddish
Very Pale
Pale with a beige tint
Light Brown
Medium to dark brown
Dark brown-black
If I go out into the sunlight for an hour or so without sunscreen and have not been out in the sun for weeks, my skin will:
Burn, blister and peel
Burn, then when the burn resolves there is a little or no colour change
Burn, but then turn to tan in a few days
Get pink, but turns to tan quickly
Just tan
Just gets darker
My skin colour is so dark i cannot tell
When was the last time the area to be treated was exposed to natural sunlight, tanning booths or artifical tanning cream?
Longer than a month ago
Within the past month
Within the past two weeks
Within the past week
Laser Tattoo Removal - Primary Consultation Form
Personal Details
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
County
Postal Code
Home Number
-
Area Code
Phone Number
Mobile Number
Email Address:
example@example.com
Any Known Allergies::
Please read the following medical history document-
If any of the following apply to you, please write them in the section below along with any medication you are taking at this time.
Please enter here in relation to the above document:
Tattoo Details:
Where on the body is the tattoo?
Was the tattoo done by an amateur or professional?
Description of tattoo?
Colours in the tattoo?
Age of tattoo?
Have you hade laser treatment for the tattoo before?
Yes
No
Country the tattoo was applied?
Has the tattoo had any touch ups applied ?
Yes
No
Touch up details (if applicable)
Any scars, moles or freckles within the tattoo?
Yes
No
Details (If applicable)
Targeted results from a course of Laser treatments (choose one)
Complete removal
Fading of existing tattoo for new cover up work
Fading of existing tattoo to cover with make-up
Q-Switched Laser Treatment Consent Form
Please read the following document . If you are happy with the form please sign at the bottom of this form
Signature
Submit
Should be Empty: