Patient Intake Form – Fadeaway Vancouver Tattoo Removal

Personal Information

Patient

Patient Full Name

Date of Birth

Phone

Address

Emergency Contact

Full Name (Emergency Contact)

Phone

Relation

Medical History

Do you have any existing medical conditions or are you under the care of a healthcare provider for any ongoing health issues?

Yes No

If yes, please list them:

Have you ever been diagnosed with an autoimmune disorder? (Examples: Rheumatoid arthritis, systemic lupus erythematosus, scleroderma, Sjogren's syndrome, mixed connective tissue disease, polymyositis, dermatomyositis, Hashimoto’s thyroiditis, Graves’ disease, multiple sclerosis, myasthenia gravis, pernicious anemia, reactive arthritis, type 1 diabetes, Crohn’s disease, psoriatic arthritis, ankylosing spondylitis, vasculitis, and celiac disease, etc.)

Yes No

If yes, please list them:

Are you currently taking any prescription medications for the treatment of such disorder(s)?

Yes No

Have you ever been diagnosed with a Connective tissue disorder? (Examples: Ehlers-Danlos syndrome, Marfan syndrome, osteogenesis imperfecta, Stickler syndrome, Loeys-Dietz syndrome, fibromuscular dysplasia, rheumatoid arthritis, systemic lupus erythematosus, scleroderma, Sjogren’s syndrome, mixed connective tissue disease, dermatomyositis, and polymyositis, etc.)

Yes No

If yes, please list them:

Are you currently taking any prescription medications for the treatment of such disorder(s)?

Yes No

If yes, please list them:

Are you currently taking any prescription medications that can cause sensitivity to the sun or UV? Some examples include:

Antibiotics (ciprofloxacin, doxycycline, levofloxacin, ofloxacin, tetracycline, trimethoprim).
Antifungals (flucytosine, griseofulvin, voriconazole)
Antihistamines (cetirizine, diphenhydramine, loratadine, promethazine, cyproheptadine)
Cholesterol-lowering drugs (simvastatin, atorvastatin, lovastatin, pravastatin)
Diuretics (thiazide diuretics: hydrochlorothiazide, chlorthalidone, chlorothiazide; other diuretics: furosemide, triamterene)
Non-steroidal anti-inflammatory drugs (ibuprofen, naproxen, celecoxib, piroxicam, ketoprofen)
Oral contraceptives and estrogens
Phenothiazines (chlorpromazine, fluphenazine, promethazine, thioridazine, prochloroperazine)
Psoralens (methoxsalen, trioxsalen)
Retinoids (acitretin, isotretinoin)
Sulfonamides (acetazolamide, sulfadiazine, sulfamethizole, sulfamethoxazole, sulfapyridine, sulfasalazine, sulfasoxazole)
Sulfonylureas for type 2 diabetes (glipizide, glyburide)

Yes No

If yes, please list them:

Are you currently taking an anticoagulant/blood thinner? (Examples: Eliquis, Warfarin)

Yes No

Have you taken Accutane in the last 6 months?

Yes No

Have you been diagnosed with diabetes?

Yes No

Have you ever experienced any light-induced seizures?

Yes No

Do you currently have any active bacterial, viral, or fungal infections?

Yes No

If yes, please specify:

Do you have any allergies to medications, whether internal (such as pills or injections) or topical (such as creams or ointments)?

Yes No

If yes, please specify:

Have you been diagnosed with HIV?

Yes No

Have you received radiation therapy or chemotherapy in the past 6 months?

Yes No

Have you had an organ transplant?

Yes No

Are you currently pregnant or trying to become pregnant?

Yes No

Are you currently breastfeeding?

Yes No

Do you smoke or vape?

Yes No

Tattoo Information

What is the age of the tattoo you wish to remove?

Does your tattoo contain any colors other than black?

Yes No

If yes, please list the colors

Do your tattoo(s) ever feel more itchy or irritated than your non tattooed skin?

Yes No

Did you have any scars or burns in the area previous to getting your tattoo?

Yes No

After healing, does any part of your tattoo ever feel elevated (raised) or textured (bumpy)?

Yes No

How would you describe the healing process you experienced after your tattoo(s)?

Smooth and uncomplicated – No issues; healing was straightforward. Minor irritation – Some redness, itching, or discomfort, but nothing significant. Prolonged healing – Took longer than expected with noticeable dryness, scabbing, or sensitivity. Problematic healing – Experienced significant issues like infection, excessive scabbing, or persistent discomfort.

Have you previously undergone any tattoo removal treatments?

Yes No

Approx date of last session?

Method used?

Any complications with healing?

Skin Sensitivity & Exposure

Do you have a history of keloid scarring (generally appear as raised red scars)?

Yes No

Do you have a history of any skin conditions? Some examples include: Eczema, Psoriasis, Contact Dermatitis, etc)

Yes No

If yes, please list them:

What happens to your skin if you stay in the sun for an extended period?

How tanned do you get after sun exposure?

How often do you tan (sun or artificial)?

Never - always wearing SPF / avoids sun exposure Rarely - occasional UV exposure from daily tasks Sometimes - seasonal exposure during summer months or vacation Often - weekly sun exposure due to outdoor activities Always - works outdoors, lives in a sunny area, or enjoys sun exposure or artificial tanning

Certification & Signature

By signing below I certify that the information provided above is accurate and complete to the best of my knowledge. I understand that withholding information may affect the outcome of my treatment.

Patient Full Name

Date Signed

Patient Signature

Guardian Information (if patient is under 18)

I, as the legal guardian of the minor named above, authorize the tattoo removal procedure on their behalf. I certify that the information provided is accurate and complete to the best of my knowledge. I understand that any omission or incorrect information could impact the outcome of the treatment. I assume full responsibility for this decision and acknowledge that I have been fully informed of the procedure’s risks and benefits.

Guardian Full Name

Date Signed

Guardian Signature

For Office Use Only

Fadeaway Representative Name

Date Signed

Fadeaway Representative Signature

(778) 806-FADE (3233)

info@fadeawayvancouver

fadeawayvancouver.com

750 West Broadway, Suite #901,

Vancouver, BC V5Z 1H8

(778) 806-FADE (3233)

info@fadeawayvancouver

fadeawayvancouver.com

750 West Broadway, Suite #901,

Vancouver, BC V5Z 1H8

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