STRIMLING DERMATOLOGY, LASER & VEIN INSTITUTE Tattoo Removal New Patient Info / Exam Form New Patients / Clients – Please download, print and complete the following demographic information and bring with you to your scheduled appointment. Thank you! Pt Name___________________________________________________________________________DOB____________________________ Age__________ M / F Date of Service_____________________________ Mailing Address______________________________________________________________________________ City, State: Las Vegas, NV or_____________________________________________ Zip_________________ Home Phone #_____________________________________________________ Mobile (Cell) #_____________________________________________________ Work #__________________________________________________ May we contact you via email? If yes, Email address:______________________________________________________________________________________________________________________________________________ Allergies to Medications:____________________________________________________________________________________________________ __________________________________________________________________________ Medications:___________________________________________________________________________________________________________________________________________________________________________________________ Laser tattoo removal requires between 3-12 or more treatments? Forms of payments accepted include: cash, credit card or financing via CareCredit. If you would like information about financing via CareCredit, please ask on our one of our cosmetic consultants for more information. The following Information will be completed by our Staff: Here For Laser Tattoo Removal V Skin Assessment: Fitz Skin Type (circle): I II III IV VI Allergies:_______________________________________________________________________________________________________ Meds / Products:_________________________________________________________________________________________________ (Relative & Absolute) CONTRAINDICATIONS FOR ALL/Most COSMETIC PROCEDURES (Review w/ Patient & Inform MD prn) Pregnancy or trying / Nursing / History of abnormal healing or scarring (e.g. keloid scarring) to previous laser or surgery Medications (Aspirin, Plavix w/i 1 week & Motrin / Advil, Coumadin w/i 3 days before laser) or other conditions that promote BLEEDING Accutane w/i one (1) year HIV / AIDS Hepatitis C Immunosuppressed (On Chemotherapy / Medications / Medical Conditions) H/O of Radiation to treatment site Active skin infection (including cold sores / herpes, warts) or inflamed Dermatitis (or h/o) in area/s to be treated Active Systemic Infection or Illness Vitiligo Wounded, sunburned / suntanned, excessively sensitive skin Skin types 5 & 6 (Requires caution, lower fluences and more treatments) Add’l BBL (IPL) & 532 nm Laser Tattoo Removal Contraindications / Precautions: Very recent sun exposure or tanning Hypersensitive to light or have photosensitive conditions [e.g. lupus (& other similar connective tissue diseases), light triggered seizures] Medications (e.g. Accutane, TCN, Gold, Saw Palmetto, Ma Huang) that promote photosensitivity – refer to list Add’l Laser Tattoo Removal Precautions: Avoid Face, Pigmented Nevi (Moles), and Skin Colored (White, Peach/Pink, Tan) Tattoos & Artificial/Permanent Make-up other Medical Conditions__________________________________________________________________________________ (No) above CONTRAINDICATIONS (FOR ALL/Most COSMETIC PROCEDURES) PRECAUTIONS: [Check box if positive (“yes”)] PRE-/ Post-Procedural Checklist: Make sure patient has complied with all pre-treatment instructions and signed informed consent and has all post-procedural care instructions / handouts. All patient’s questions answered Carefully examined skin before procedure (avoid inflamed/irritated areas – ask MD prn) Photographs taken per protocol Remove all sunblock / mositurizer / make-up and jewely (in or near areas to be treated). Pull hair back with headband or surgical cap, as needed Cover patients eyes with total block eyeshields or appropriate wavelength protective eyewear for all IPL / Laser procedures. Laser Sign on Door (if Laser in Use) Procedure: Laser Tattoo Removal PE findings / Recommendations &/or Procedure type, Anesthesia, Locations / Parameters, Description, Any Adverse Reactions & Tx Plan etc.: # of Tattoos (if more than one) ____________ Location(s) & Description of Tattoo/s (& Colors)___________________________________________________________________________________________________________ ______________ Location(s) & Description of Tattoo/s (& Colors)_________________________________________________________________________________________________________________________________________________________________________ Size(s) of tattoos (inch x inch = inches2)___________________________________________________________________________________________ _______________________________________________________________________________________ Numbing Cream or Local Lidocaine____________________________________________________________________________________________________________________ __________________________________________________________ Laser Settings / Previous Scarring / Other ________________________________________________________________________ ____________________________________________________________________________________________ Laser Log(s) done. Quote______________________________________________________________________________________ Post-procedural care discussed verbally, as per treatment specific provided post-care instructional handouts HS Prophylaxis given prn (Valtrex 500 mg bid x 5-10 days / Start am of Tx ) Patient was instructed to contact our office should any problems arise, esp S/S of wound infection (as instructed.) FU in __________ days / weeks / months. Amount Charged $ _________________________ / Paid $ _________________________ V / MC / AMEX / D / Cash / Care Credit / #________________________ / Other________________________Initials Provider Sig________________________