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The Florida Department of Health works to protect, promote & improve the health of all people in Florida through integrated state, county & community efforts.

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Tattooing

Black Henna Tattoo Form

Contact the Tattooing Program

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:

Legal Guardian First Name (if individual is a minor):

Legal Guadian Last Name (if individual is a minor):

Address:

City:

State:

Phone #:

Email address:

Name of Facility:

Address of Facility:

City Facility is located in:

Phone # of Facility:

Date of Application dd/mm/yyyy: (i.e. 06/17/1977)

Date of Reaction dd/mm/yyyy: (i.e. 06/17/1977)

Current Status of Condition:

Do you have images to submit for our records?

Yes

Additional Comments:

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Tattooing

Black Henna Tattoo Form

Contact the Tattooing Program