Home
About Us
Book
Gallery
Price Guide
FAQ
Contact Us
CLIENT CONSULTATION
About You
Your Health
Medical History
Medication
Your Skin
Name
*
Date
Address
Date Of Birth
Suburb
City
Postcode
Work
Home
Mobile
Other
Email Address
*
How did you hear about us?
Area and age of tattoo
What previous removal methods have you tried?
Are you currently under a doctor’s /healthcare practitioner’s care?
Yes
No
If yes, for what?
There are contra-indications to Laser treatments that may cause damage to the skin so please answer the following honestly;
Have you had significant sun exposure in the last 4 to 6 weeks?
Do you use sun beds, spray-tanning products or tinted moisturisers?
Do you have blood disorders or infectious diseases?
Are you currently pregnant or trying to conceive?
Have you ever experienced or been treated with / for the following:
Epilepsy
Keloid
Pacemaker
Skin Cancer
Heart condition
Photosensitising Drugs
Warfarin
Roacutane
Cancer – current treatment
Herpes [oral/genital]
Cold Sores
Diabetes
Metal Implant/piercings
Anti Coagulants
Hormonal Condition
Hormonal Medication
Lack of Sensation
Allergy to topical anesthesia
Skin Disorder
Aspirin
Allergies
Medical Condition
Skin Pigment – on treatment site
Anti-inflammatory Drugs
Lack of Temperature Awareness
Please explain and include dates / details:
Have you ever had any of the following on or near the treatment site:
Chemical Peel
Micro Dermabrasion
Implants
Botox, injectables
Resurfacing or fractional Laser
Surgery in treatment area
Please explain and include dates / details:
Please list all PAST medications used in the last 3 months:
Please list all CURRENT medications:
Please list all CURRENT vitamin supplements, herbal remedies:
Skin Type
Always burns easily, never tans and is extremely sensitive to the sun (Red-haired, freckles, Celtic, Irish-Scots )
Always burns easily, tans minimally, very sun sensitive skin (Fair-skinned, fair-haired, blue-eyed, Caucasian)
Sometimes burns, tans gradually to light brown, sun sensitive skin (Average Skin)
Burns minimally, always tans to moderate brown, minimally sun sensitive skin (Mediterranean-type Caucasian)
Rare burns, tans well, sun insensitive skin (Middle Eastern, some Hispanics, some African American )
Never burns, deeply pigmented, sun insensitive skin (African American)
Ethnic background
Any other nationalities in family tree
Eye colour
Natural hair colour
Natural skin colour on area that is unexposed to sun (area to be viewed):
Skin Characteristics
Does skin burn easily with sun exposure
Does skin tan easily
If injured [burned, cut], does the skin heal leaving a dark, pigmented mark?
Does any close family member have skin that is darker or paler?
Website Built By
FTI Technologies
