Name *

First Name

Last Name

Has the tattoo been touched up, redone, or covered up?

Yes, just touched up in spots

Yes, completely redone

Yes, this tattoo is a cover up

No

Is the tattoo scarred?

Yes, it is raised at all times

Maybe, the lines get raised sometimes

I'm not sure

No

How did the tattoo initially heal?

No issues

It scabbed and/or became infected

I had an allergic reaction and/or it took several months to heal

Are you pregnant or nursing?

Yes

No

Have you taken Accutane within the last 12 months?

Yes

No

Do you have Type I or Type II Diabetes?

Yes

No

Are you currently taking any immunosuppresant drugs?

Yes

No

Do you have circulation issues like PAD or CHF?

Yes

No

Where did you receive the tattoo ?

A professional tattoo shop

A residential setting (an amateur tattoo)

Prison and/or jail

Other