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 #__________________________________________________
Marital Status:  Single / Divorced  Married
#_________________________________________________
Emergency Contact Name (& Relationship)_________________________________________________________________ Emergency Contact
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________________________