LASER TATTOO REMOVAL — intake & consultation

Datos personales y médicos

• Name.
• Date of Birth.
• Date of Consult.
• Address.
• City.
• State.
• Zip.
• Phone Number.
• Email Address.
• Gender: M / F / O.
• How did you hear about us?: Facebook / Friend / Other.
• Are you currently taking any medication?: ☐ Yes ☐ No.
• Do you have any allergies or intolerances?: ☐ Yes ☐ No.
• Do you use the contraceptive pill, other hormone therapy or fertility drugs?: ☐ Yes ☐ No.
• Are you pregnant, planning a pregnancy or breast feeding?: ☐ Yes ☐ No.
• History of bleeding/coagulation or clotting disorders / use of anti-coagulants: ☐ Yes ☐ No.
• Skin disorder / psoriasis / eczema / vitiligo / dermatitis / melasma / inflammatory skin condition: ☐ Yes ☐ No.
• Skin pigmentary conditions - hyperpigmentation / moles / pigmented naevi: ☐ Yes ☐ No.
• Coronary / Pacemaker / Blood pressure conditions: ☐ Yes ☐ No.
• Select all that apply: Asthma / Kidney Disease / Diabetes / Depression / Liver Disease / Hemophilia / HIV / Other mental health disorder / Cancer / Herpes/cold sores / Epilepsy.
• Additional Comments.