Medical History Form
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Number
-
Area Code
Phone Number
Email Address
*
example@example.com
Date of Birth
*
-
Day
-
Month
Year
Date
What is your gender?
Please Select
Male
Female
N/A
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Number
*
Format: (000) 000-0000.
How did you hear about us?
*
Have you had Laser Tattoo Removal Before? If yes, who did your treatment/s?
Do you have ANY current or chronic medical illnesses listed below?
Heart Urticaria
Cancer
Diabetes
Bacterial or Viral Infections
Autoimmune Disorders
Skin Photosensitivity Disorder
Blood Disorders (HIV, Hepatitis, etc)
Hormone Imbalances
History of Keloid Scarring
Seizures
Suspicious Moles under your tattoo
Other
Are you currently taking any medication?
Yes
No
Medication List
*
CONTRAINDICATIONS Therapy using the ND YAG-Q Switch laser for tattoo removal is contraindicated for those clients who have any of the following conditions. Select if any of these apply.
Hypersensitivity to infrared wavelenghts
Taking medications which are known to increase sensitivity to sunlight
Taken Isotretinoin such as Accutane within the last 6 months
Open wound in the treated area
History of healing problems
History of 'Erythema Ab Igne'
Hyperpigmentation or Hypopigmentation
Mechanical or Chemical Epilation in the last 6 weeks
Other
Do you have any allergies?
Yes
No
Not Sure
Allergies List
WOMEN: Are you trying to conceive or are you pregnant?
Yes
No
WOMEN: Are you Breastfeeding?
Yes
No
Submit
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