Tattoo Removal Client Intake Form
For consultation
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
-
Month
-
Day
Year
Date
Emergency Contact Name & Number
Name
*
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Which service do you require
*
Full Tattoo Removal
Partial Removal
Microblade Eyebrow Ink Removal
MED.SPA
Health History
*
Do you have any allergies , especially to skincare products, medication or pigments ?
Yes
No
If Yes, please list
List
Are you currently taking any medication ?
Yes
No
If yes please list
List
Do you have any of the following medical conditions
*
Diabetes
Blood Clotting Disorders
Skin conditions ( eczema, psoriasis etc )
Autoimmune Disorder
Pregnancy or Breastfeeding
Heart Condition
Cancer ( current or history )
Any Other Chronic Conditions ( please specify )
No
Specify
Have You Had Any Previous Laser Treatments Or Skin Treatments
*
Yes
No
If Yes , please provide details
Details
Do you have any tattoos in the treatment area
*
Yes
No
Tattoo History : How old is the tattoo you wish to have removed
Less than 1 year
1-5 years
5 + Years
What is the size of the tattoo you want to remove
*
Small ( Less than 2 inches )
Medium ( 2-5 inches )
Large ( 5 + inches )
What Colors are in the tattoo
What is the reason you want the tattoo removed
Personal Resons
Professional Resons
Faded or Unattractive
Other ( please specify )
Specify
Skin & Sensitivity: What is your skin type
*
Very Fair
Fair
Medium
Olive
Dark
Have you ever experienced any of the following skin reactions ( Please check all that apply )
*
Sacrring
Hyperpigmentation ( dark spots )
Hyperpigmentation ( light spots )
Excessive redness or irritation
Sun sensitivity
Do you tan easily or use tanning beds
*
Yes
No
Have you recently been exposed to the sun or used a tanning bed
*
Yes
No
If yes , when was the last exposure
Laser Tattoo Removal Information
*
Do you understand that multiple sessions may be required for complete removal
Yes
No
Do you have any questions or concerns about the laser tattoo removal process
Consent & Acknowledgement
I hereby consent to the use of laser tattoo removal treatment as discussed with kplasertattoo. I understand that there are risks involved, including but not limited to scarring , changes in skin pigmentation, and discomfort during the procedure. I confirm that all the information provided in this form is accurate and complete to the best of my knowledge .
*
I Agree
Client Signature
Date
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Month
-
Day
Year
Date
Practitioner Signature
Date
-
Month
-
Day
Year
Date
Save
Continue
Continue
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