Patient Update 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

Since your last session, have there been any changes in the following areas:

Have you started, stopped, or changed any medications?

Yes No

If yes, please provide details

Have you been diagnosed with any new medical conditions or experienced changes in existing conditions?

Yes No

If yes, please provide details

Have you developed any new allergies or experienced changes in existing allergies?

Yes No

If yes, please list them:

Treatment Progress & Healing Assessment

Have you noticed any changes in your skin’s condition in the areas being treated (e.g. new sensitivities, rashes, scars)?

Yes No

If yes, please list them:

Have you noticed any changes in your skin’s condition in the areas being treated (e.g., new sensitivities, rashes, scars)?

Very diligent (Followed all instructions carefully) Mostly diligent (Followed most instructions) Somewhat diligent (Followed instructions inconsistently) Not very diligent (Rarely followed instructions) Not diligent at all (Did not follow instructions)

If you have any further information or comments on this please elaborate:

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