Consultation Form | BARE by Marlese

Client Details

Date of Birth *

Contact Number *

Tattoo Information

Approximate age of tattoo * Location on body * Have you attempted removal before? (Laser, saline, creams) If yes, please describe

Tattoo Characteristics

Type of tattoo *

Professional Amateur Cosmetic / PMU Not sure

What colours are in the tattoo? *

Black Blue Green Red Yellow White Multi-colour Not sure

Is the tattoo raised or scarred? *

No Yes

Have you ever had a reaction to your tattoo ink? *

No Yes

If yes, please describe Is this tattoo a cover-up of another tattoo? *

No Yes Not sure

Fitzpatrick Skin Type

This helps us choose safe laser settings and reduce the risk of pigmentation changes.

Your Fitzpatrick skin type

Taking the test will open in a new tab. When you finish, your result will automatically fill here.

Medical History & Safety

Do you have or have you ever been diagnosed with any of the following conditions? *

Lupus Psoriasis Vitiligo Eczema / dermatitis Keloid scarring Diabetes Autoimmune disorder Immunosuppressive medication or therapy (e.g. biologics, chemotherapy, steroid therapy) None of the above

Other (please specify)

Treatment Safety *

Currently pregnant or breastfeeding Recent sun exposure or tanning beds in the last 4 weeks Using any photosensitising medication or products Moles or suspicious lesions in treatment area Active infection in treatment area Recent chemical peel in treatment area Tattoo done within the last 6–8 weeks History of poor wound healing or abnormal scarring None of the above

Viral & Blood-Borne Conditions *

History of cold sores (Herpes Simplex Virus) Hepatitis B Hepatitis C HIV None of the above

Other blood-borne condition (please specify)

Chronic Health Conditions *

Diabetes (Type I or II) Epilepsy or history of seizures Heart condition or pacemaker Bleeding disorder (e.g. haemophilia) History of skin cancer None of the above

Other Chronic Health Conditions (please specify)

Allergies *

Tattoo ink allergy Lidocaine / numbing cream allergy Latex allergy No known allergies

Other allergies (please specify)

Medications & Supplements *

Have you taken Accutane (Isotretinoin) in the last 6 months? *

Blood thinners (anticoagulants) Iron supplements Gold therapy (for rheumatoid arthritis) Antibiotics taken in the last 2 weeks Retinol / Retin-A used in treatment area St. John’s Wort or other photosensitising supplements None of the above

List all current medications (including herbs, vitamins, supplements)

Lifestyle Factors

Do you smoke or vape? *

No Yes — cigarettes Yes — vape Yes — both

If yes: approximate daily use

Smoking and vaping can slow the body’s ability to clear tattoo pigment and may extend the number of sessions required.

Additional Information

Is there anything else I should know? What outcome are you hoping for?

Photos

Clear photos help us estimate sessions and treatment suitability before your consultation. Please avoid filters. Include one close-up and one photo showing the surrounding area.

Upload tattoo photos (optional)

File upload limits: max 10MB per image, up to 10 images, 30MB total combined. Accepted formats: JPG, PNG, WEBP.

By proceeding, you agree to our booking terms. A minimum of 24 hours’ notice is required for cancellations or rescheduling. Deposits may be non-transferable for late changes.