FREE, NO OBLIGATION ONLINE CONSULTATION Name * First Name Last Name Email * Phone * (###) ### #### Message * What treatment are you interested in? (required) * Magnetic PMU/Tattoo Removal Camouflage Tattooing Scar Remodeling Inkless Stretchmark Revision Skin Needling Please describe your goal or area of concern (i.e.: I would like my scar camouflaged; I want stretchmarks less visible, etc.) Date of Birth (required) * MM DD YYYY Gender Which conditions apply to you? (required) * Allergies Keloid Scars Diabetes Cold Sores Iron Deficiency Anemia Hemophilia Hypoglycemia Pregnant Now Heart Problems AIDS (HIV) Hepatitis Cancer High Blood Pressure Accutane Blood Thinners Skin Disorder(s) Menopause Pace Maker Botox Prone to Fainting Lip Fillers Cosmetic Tattoo Upcoming MRI None Current Medications (required) * Referred By/How Did You Find Us? Please email a photo of the area(s) of treatment (i.e. face, body scar, stretchmarks) to ReVisionInkPA@gmail.com Important: Clients who experience cold sores are required to take cold sore medication (Valtrex) prior to having any lip treatments. I acknowledge that any information contributed by me is true, to the best of my knowledge and that the present condition of the area that has been treated or will be treated is stated on this record. * Yes Thank you! Some one will get back to your soon!