Health History

Let us do this part

Today's Date:

Sun Jun 28 2026 10:36

Practitioner:*

Honey Ink Tattoo Studio - Laser Tattoo Removal

To provide you with the most appropriate laser tattoo removal plan, we need you to complete the following
questionnaire. A current health history is essential for your clinician to provide appropriate procedures. All
information is strictly confidential. Please note the minimum age for laser tattoo removal is 18.

Please read and answer

How did you hear about us?*

Google?
Facebook?
Instagram?
Friend/Family?
Tattooist?
Other?

Have you had Laser Tattoo Removal Before?*

If Yes, Who/Where did the treatment?

Details:

Illnesses*

Do you have ANY current or chronic Illnesses as listed below?

Heat urticaria, diabetes, autoimmune disorders or any immunosuppression, blood disorders, cancer, bacterial or viral infections, conditions that significantly compromise
the healing response, skin photosensitivity disorders, hormone imbalance, thyroid imbalance, raised scarring (keloid), or any other condition or illness.
If yes, please list:

Details:

Your Skin*

Do you have ANY current or chronic skin conditions?
Allergies?
If Yes, Please list:

Details:

Doctor's Care*

Are you currently under a doctors care?
If yes, Please list:

Details:

Hospitalization *

Have you been hospitalized for ilinesses/other:
If Yes, Please explain:

Details:

Medications*

LIST MEDICATIONS OF ALL TYPES:

Prescription and non-prescription, vitamins, herbal, natural supplements, steroids of any
kind, blood thinning medication, Accutane, tanning products oral or injectable, birth
control pill, hormones, others?
If Yes, Please list:

Details:

Allergies*

Do you have ANY allergies to medications, foods, latex, Aspirin,
Lidocaine, Hydrocortisone, Hydroquinone or skin bleaching agents or other substances?
If Yes, please list:

Details:

Women*

Are you trying to Conceive, or are you Pregnant/Breastfeeding?

Details:

Scarring History*

Please show us your scars, so we can make an assessment
of keloid or hypertrophic symptoms.

Seizures*

Do you have a history of light induced seizures?
If Yes, Please explain,

Products*

In the last three (3) months, have you used any of the following products?
Glycolic acid or other alpha hydroxy or beta hydroxy acid products; exfoliating or resurfacing products or treatments, or Retin A on a tattoo, or Tretinoin in the last 6
months on a tattoo?
If Yes, please list

Details:

Tanning*

Have you had any unprotected sun exposure, used tanning
creams (including sunless tanning lotions) or tanning beds or lamps in the last 4-6
weeks?

Blood Disorders*

Do you have hepatitis, blood thinning. AIDS?

Moles*

Do you have any moles or suspicious spots under your tattoo?

Contraindications

Therapy using the ND YAG - Q Switch laser for tattoo removal is contraindicated for those clients who have
any of the following conditions. Please circle the appropriate answer below and sign the form at the bottom.
This is to ensure the best outcome of your sessions, so please be sure to read the form carefully.

Hypersensitive *

Are you hypersensitive to light in the near infrared wavelength region?

Medication*

Do you take medication which is known to increase sensitivity to sunlight?

Medication*

Have you taken oral isotretinoin, such as Accutane®, within the last six months?

Infection/Open wound*

Do you have an active localized or systemic infection, or an open wound in the area being treated?

Systemic Illness*

Do you have a significant systemic illness or an illness localced in the area being treated e.g. lupus?

Melanoma*

Do you have common acquired nevi that are predisposed to the development of malignant melanoma?

Medication*

Do you take medications that alter the wound-healing response?

Healing/Scaring*

Do you have a history of healing problems or history of raised scarring (keloid) formation?

Skin Cancer/Lesions*

Do you have a history of skin cancer or suspicious lesions that you are concerned about?

Skin Rash*

Do you have a history of erythema ab lane, which is a persistent skin rash produced
by prolonged or repeated exposure to modertevintense heat or infrared irritation?

Pigment*

Do you have hyperpigmentation (darkening of the skin) or hypopigmentation
(lightening of the skin) or marks after physical trauma?

Epilation*

Have you had chemical or mechanical epilation within the last six weeks?

Acknowledgement*

I certify that the preceding in medical, personal and skin history statement are true and correct.
I am aware that it is my responsibility to inform Honey Ink of my medical or health conditions and to update this history.

If any provision, section, subsection, clause or phrase of this release is found to be unenforceable or invalid, that portion shall be severed from this contract. The remainder of this contract will then be construed as though the unenforceable portion had never been contained in this document.

Client Information

I hereby declare that I am of legal age (with valid proof of age) and am competent to sign this Agreement.

Name:*

Address:*

Postcode:*

Date of birth:*

You must be 18 or older

Age:

Gender:

Nationality:

Phone #:*

Email:*

Signature:*

Sign or type signature:

Emergency Contact

If something happens, your emergency contact might need to explain your medical history, allergies, or medications.

Name:

Phone #:

Physician Information

Enter your physician or medical practitioner's contact details.

Name:

Contact:

Address: