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Facilities
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:
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Additional Comments:

 
This page was last modified on: 09/18/2012 07:17:06