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PMU & Tattoo Removal Intake Form

Client Information:

Birthday
Day
Month
Year

Medical Questionnaire:

Do you have any of the following (please circle YES or NO):

Skin conditions (eczema, psoriasis):
YES
NO
Keloid scarring history:
YES
NO
Diabetes:
YES
NO
Epilepsy:
YES
NO
Pregnancy or breastfeeding:
YES
NO
Use of Accutane in last 6 months:
YES
NO
Allergies:
YES
NO
Current medications:
YES
NO
Any recent sun exposure/tanning:
YES
NO

Procedure: PMU & Tattoo Removal

Consent for photographs:
YES
NO
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