Black Henna Tattoo Submission Form

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Under Florida law, information submitted to the department may be deemed public record. If you do not want your information released in response to a public records request, do not send electronic mail to this entity.

Contact information:
First Name of Individual affected:
Last Name of Individual affected:
Age:
Sex:	Male Female
Race:
If this concerns a minor, please submit parental or legal guardian information.
First Name:
Last Name:
Address:
City:
State:
Phone #:
Email address:

Location of Tattoo Facility:
Name of Facility:
Address of Facility:
City Facility is located in:
Phone # of Facility:

Condition Information:
Date of Application dd/mm/yyyy: (i.e. 06171977)
Date of Reaction dd/mm/yyyy: (i.e. 06171977)
Current Status of Condition:
Do you have images to submit for our records?	Yes No
Additional Comments:

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