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Serving the Washington Metro Area from Locations in Maryland, Virginia, and DC
(202) 621-8675
Mcelaser@gmail.com
Click to request an appointment
About Dr Varano
About Dr Varano
Our Philosophy
Services
Services
Botox/Dysport/Jeuveau/Daxxify
Coolsculpting Elite
Cooltone
Fraxel & Fractional CO2
Hair Restoration
IPL Photofacial
Kybella
Laser Hair Removal
Liposuction & Laser Lipo
Medical Camouflage Tattooing
Weight loss with Semaglutide
RF Microneedling, Hydrofacials & Microderm
Microneedling Plus
Miradry
Renuvion J-Plasma Body Contouring in Washington, DC
Restylane & Juvederm
Silhouette Instalift
Tattoo Removal
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Our Policy & Forms
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Tattoo Removal
> Tattoo Removal Questionnaire
Tattoo Removal Questionnaire
Please remember to also schedule a phone consult or go back to the tattoo removal page after you submit this form. Fields marked with an * are required fields.
First Name
*
Middle Initial
*
Last Name
*
Street Address
*
City, State Zip
*
Phone 1
*
Phone 2
*
Email
*
Occupation
Date of Birth (mm/dd/yy)
*
Please list the prescriptions you are currently taking:
*
Drug allergies:
*
Tattoo Size
Please check the size of the tattoo:
2 Square Inches
4 Square Inches
9 Square Inches
16 Square Inches
25 Square Inches or Larger
Check all that apply:
Check all that apply:
Pregnant or Nursing
Ink Allergy
Tattoo older than 20 years
Immunocompromised
On Gold products
Have permanent cosmetic makeup removed
History of Lupus
Recently Tanned
Allergy to topical anesthesia (Lidocaine)
Please indicate your skin type:
Please indicate your skin type:
Caucasian-burn easily/rarely tan
Caucasian-can tan
Olive/Asian/Hispanic/Mediterranean
African American-Light/Middle Eastern
African American-dark
Please check all colors that apply to your tattoo:
Please check all colors that apply to your tattoo:
Black
Yellow
Red
Orange
Dark Blue
Green
Tan
Violet
Where is your tattoo located?
Where is your tattoo located?
Neck
Below Belt
Chest/Back/Abdomen
Upper Leg/Upper Arm
Hand/Wrist/Forearm/Ankle/Foot
Was your tattoo made by an amateur?
Was your tattoo made by an amateur?
Yes
No
Was your tattoo done by a professional?
Was your tattoo done by a professional?
Yes
No
Which best describes your tattoo?
Which best describes your tattoo?
One Color
Mulit-color
Complex Design
Is your tattoo a cover up of an old one?
Is your tattoo a cover up of an old one?
Yes
No
Have you had any prior laser tattoo removal treatments?
Have you had any prior laser tattoo removal treatments?
Yes
No
If yes how many prior sessions?
If you have had a prior session, list approximate treatment date:
Do you have any scars over the tattoo?
Do you have any scars over the tattoo?
Yes
No
Pharmacy Phone # (to call in anesthetic cream)
Upload a picture of your tattoo
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