Black Henna Tattoo Form - Florida Department of Health

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.

This field is for validation purposes and should be left unchanged.

Name of Individual affected:

First Last

Age:

Sex:

Male

Female

Race:

Legal Guardian Name (if individual is a minor):

First Last

Address

Street Address Address Line 2 City State

Phone #

Email address:

Name of Facility:

Address of Facility:

Street Address Address Line 2 City State ZIP Code

Phone # of Facility:

Date of Application:

Date of Reaction

Current Status of Condition:

Do you have images to submit for our records?

Yes

Additional Comments: