Clean Slate Solution™ – SB1804 Tattoo Removal Intake Form
Confidential Inquiry Form for SB1804 Funding Eligibility KPLaserTattoo | Love at First Sight MedSpa – Brownsville, TX
Full Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Preferred Contact Method
Call
Text
Email
Do you have a tattoo that was applied against your will?
Yes
No
Not sure
Where is the tattoo located on your body?
What is the content of the tattoo (if known)?
When did you receive the tattoo?
Do you believe the tattoo is related to a trafficking, coercion, or abuse situation?
Yes
No
Unsure – would like to speak confidentially
Are you willing to speak with a legal advocate to verify your eligibility under SB1804?
Yes
No
I have questions
Additional Notes (Optional)
UP TATTOO IMAGE
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