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  1. Please include full international dialing code
  2. Full Name of the client who recieved the cosmetic tattoo treatment

  3. Full Name of the Cosmetic Tattooist who provided the initial cosmetic tattoo treatment



  4. What is your relationship to the Adverse Outcome?
  5. Date that the treatment was provided
  6. The date that the adverse outcome was first noticed
  7. What country was the treatment provided?
  8. What suburb was the initial cosmetic tattoo service provided in?
  9. What is the highest qualification that the initial treating cosmetic tattooist held?
  10. Details if answered 'Other' above
  11. The main adverse outcome that is of concern
  12. Is there a second adverse outcome from the same procedure?
  13. Is there a third adverse outcome from the same procedure?


  14. Did the Client/Patient need medical treatment as a direct consequence of the adverse outcome?
  15. What kind of cosmetic tattooing was provided
  16. Details if answered 'Other' above
  17. Describe the treatment that was provided including any unusual aspects

  18. Describe the adverse outcome and any corrective/remedial treatment provided.

  19. Was the client taking/using any; medications, supplements, or skin treatments, or engaging in any other activities that may have contributed to the adverse outcome?

  20. Did the client have any medical complaints that may have contributed to the adverse outcome?

  21. What brand and type of pigments were used that may have contributed to the adverse outcome?

  22. What tattoo device was used that may have contributed to the adverse outcome?

  23. What consumable supplies were used that may have contributed to the adverse outcome?

  24. What in your opinion was the most likely cause of the adverse outcome and what preventative measures could be taken?



  25. You can include pictures with the report if you have full written consent of the client in the pictures or if you are the client.
  26. You can include pictures with the report if you have full written consent of the client in the pictures or if you are the client.
  27. You can include pictures with the report if you have full written consent of the client in the pictures or if you are the client.
  28. You can include pictures with the report if you have full written consent of the client in the pictures or if you are the client.





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