Healing Concern (HC Form)

Removal Client 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
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 *
Client Gender *

MaleFemaleOther
Client Genetic Ethnicity
Multiple choices can be selected by holding down the control or command key on computers
Tattoo Location*
Tattoo Description*
Estimate date Tattoo was finished on

MonthDayYear
Date
Your Name

First NameLast Name
Your Residence address & City
Address and City
Your 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?
Instigating Session in Series *

FirstSecondThirdFourthFifthSixth
Prior Treatment Date {where applicable)

MonthDayYear
Instigating Treatment Date*

MonthDayYear
Healing Concern Date *

MonthDayYear
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 and Healing Photos*

Upload Healing Photos from Client

Cancelof
Should be Empty:

Removal Client Healing Concern (HC Form)

Client and Tattoo Description

Instigating Treatment and Healing Concern

Photographic Record

Instructions for submitting photographs and data forms.