Healing Concern (HC Form)

Healing Concern (HC Form)

Submitted to RMI
Form Version and Date Code
Today's Date *

MonthDayYear
Date
Submitter Name*

First NameLast Name
Submitter Email*
example@example.com
Submitter Phone*

Country CodeArea CodePhone Number
Technician Name*

First NameLast Name
RMI Cert code *
This is the same as your TU login username, also printed on your Technician Certificate
Tatt2Away Center Business Name *
Tatt2Away Center Address & City*
Address and City
Tatt2Away Center State or Province*
City, State or Province
Tatt2Away Center Region (if applicable)
Region
Tatt2Away Center Country*
Client and Tattoo Description
Client Age *
MaleFemaleOther
Client Genetic Ethnicity
Multiple choices can be selected by holding down the control or command key on computers
Enter Clients Total KD Score*
Tattoo Location*
Tattoo Description*
Estimate date of Session Tattoo was finished on

MonthDayYear
Date
Provide the following contact information ONLY when the client desires direct contact with RMI.
Client Name

First NameLast Name
Residence address & City
Address and City
Residence State or Province
City, State or Province
Residence Country
Client Email [32]
example@example.com
Client Phone [33]

Country CodeArea CodePhone Number
Instigating Treatment and Healing Concern

Which TEPR treatment session in the planned series instigated the healing concern?
FirstSecondThirdFourthFifthSixth
Number of Tegulae Excised *
Note: One full hex template has 138 apertures.
Prior Treatment Date {where applicable)

MonthDayYear
Before instigating treatment
Instigating Treatment Date*

MonthDayYear
Notes Date 43 44 and 45 are in order.
Healing Concern Date *

MonthDayYear
When the Client first noticed the concern.
Healing Concern Description*
Photographic Record

All Available photographs MUST be submitted. Photographs submitted by technicians are expected to be high quality: high resolution, in focus, and uniformly lite. Immediate PRE- and POST-treatment photographs taken during EACH treatment session are part of every TEPR protocol. At a minimum, these photographs will be available and must be submitted.
Instructions for submitting photographs and data forms.

Please change the file names from the earliest "01" to the latest to keep them in sequence before uploading.
Treatment Photos (taken by the Technician)*

Upload Treatment Photos

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Healing Photos (taken by the Technician)

Upload Healing Photos taken by Technician

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Healing Photos (taken by the Client)

Upload Healing Photos from Client

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Consultation and Treatment Data Forms

Upload the following Tatt2Away forms for the client and their treatment. Make sure these are copies of the SIGNED documents you scanned of photographed.
Client History and Status (CHS1, CHS2)*

Upload Client History and Status Form

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Informed Consent and Release (ICR1, ICR2)*

Upload Informed Consent and Release Forms

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Treatment Plan (TP)*

Upload Treatment Plan Forms

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Treatment Record (TR)*

Upload Treatment Record Forms

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Technician Evaluation and Comments*
Include whatever is relevant to this concern with details necessary to explain specific responses
Should be Empty:

Healing Concern (HC Form)

Client and Tattoo Description

Instigating Treatment and Healing Concern

Photographic Record

Instructions for submitting photographs and data forms.

Consultation and Treatment Data Forms