Houston's Premium Laser Tattoo Removal Clinic

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Client Information & Medical History Form

Please complete the following questionnaire prior to treatment. All information is strictly confidential.

Today's Date(Required)

MM slash DD slash YYYY

Gender(Required)

Female

Male

Client Name(Required)

First Last

Phone Number(Required)

Date of Birth(Required)

Month

Day

Year

Occupation(Required)

Home Address(Required)

Street Address City ZIP / Postal Code

Preferred Way of Communication(Required)

Text Message

Phone Call

Email(Required)

Emergency Contact Name(Required)

First Last

Phone Number(Required)

How did you hear about us? (Please circle one)(Required)

Google Search

Bing Search

Facebook

Instagram

Tattoo Artist Mike Cruze

US Army Recruiter

Other

Which of the following picture best decribes your skin type?(Required)

Location of your Tattoo(s)(Required)

How old is your tattoo(s)?(Required)

Between 0 – 1 Year

Between 1 – 3 Years

Between 3 – 6 Years

Between 6 – 9 Years

Between 9 – 12 Years

Older than 12 Years

Is your tattoo homemade or professional?(Required)

Homemade

Professional

Short description of you tattoo(s)(Required)

Medical History: Are you currently under the care of a physician?(Required)

Yes

Please describe for what you're under the care of a physician.

Are you currently under the care of a dermatologist?(Required)

Yes

Please describe for what you're under the care of a dermatologist.

Have you ever had a reaction to a previous laser treatment, heat treatment, or radiation therapy?(Required)

Yes

Do you have any of the following medical conditions? (Please check all that apply)(Required)

Cancer

Diabetes

Herpes

Arthritis

Frequent cold sores

HIV / AIDS

Keloid scarring

Skin disease / Skin lesions

Seizure

Hepatitis

Blood clotting abnormalities

Any active infection

None of the above

Do you have any other health problems or medical conditions?(Required)

Yes

Medications

Are you currently taking any oral medications?(Required)

Yes

Plese list what oral medications you currently take.(Required)

Have you ever taken Accutane for acne?(Required)

Yes

When did you last use Accutane?

Do you use any topical medication or creams like Retin-A or others?(Required)

Yes

What topical medications or creams do you currently use? Please list:

Have you ever had an allergic reaction to any medication?(Required)

Yes

Do you currently have a sunburn?

Yes

Do you form thick or raid scars from cuts or burns?(Required)

Yes

Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma?(Required)

Yes

COVID 19: Do you currently have symptoms of COVID 19? (Loss of Taste or Smell, Fever, Cough or Chills)(Required)

Yes

Have you had COVID 19?(Required)

Yes

When was it?

MM slash DD slash YYYY

Are you pregnant or trying to become pregnant?(Required)

Yes

Are you breastfeeding?(Required)

Yes

Consent(Required)

I agree to the privacy policy.

I certify that the preceding medical, personal and skin history statements are true and correct. I am aware that it is my responsibility to inform the technician, doctor, or nurse of my current medical or health conditions and to update this history. Current medical history is essential for the caregiver to execute appropriate treatment procedures.

Request price quote for laser tattoo removal

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Clinic Hours

Monday-Friday 8am-8pm

Saturday 9am-2pm

Sunday Closed