Today's Date

Name Nickname

Age Date of Birth Male Female

Ethnicity/Race

Address
City Zip

Mailing address for program info (if different) City Zip

Home Phone Pager/ cell phone
Work Phone Other Phone/ e-mail
OK to leave messages at home? Yes No
If not, what is the best number to use?

Your primary language:
Do you need information translated? Yes No

Marital status: Single Married Separated Divorced
How many children do you have? Are You Pregnant? Yes No
Do you have a doctor or clinic Yes No
Do you need help finding one? Yes No

Who are you living with? alone parents spouse signif. other roommate

If under 18 or living at home, Name of Parent/Guardian
Phone of parent/guardian if different
Parent’s primary language
Parents/guardian know about the tattoos? Yes No
Parents/guardian know you want them removed? Yes No

Name & number of person who will know where you are
if you can’t be reached at above:
Name Phone

Are you in school? Yes No - If yes, Where?
Are you employed? Yes No
Are you on probation or parole? Yes No

I want my tattoos removed because they are affecting (check all that apply):
my self-esteem my ability to gain employment
my current job status my personal safety