Black Cat Tattoo
Consent to Tattoo Procedure
Shop Address
Black Cat Tattoo 659 Johnson Street, Downtown Victoria, BC
Tattoo Artist Name (required)
*
Cate Webb
Grae Salisbury
Elise
Cam
Kaman
Angela
Nae
Samantha
Teagan
Finbar
Vic Lee
Tahtyana
Apprentice Mica
Apprentice Taylor
- Guest Artist -
Guest Artist's Name
*
Client Information
Name
Name as it appears on ID
Pronouns
Age
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Accessibility
If you have any accessibility needs or concerns please let your artist know. We will do our best to accommodate. If you haven't been to our shop before, it should be noted that Black Cat is a second floor space with a steep staircase.
Pre-Procedure Questionnaire
Are you coming from out of town (Victoria)
No
Other
Are you under the influence of drugs or alcohol?
Yes
No
Are you pregnant or nursing?
Yes
No
Do you have a communicable disease?
Yes
No
Skin conditions (e.g. Rashes, eczema, infection, psoriasis, etc.)
If yes, please identify the condition.
Medical History (e.g. DIabetes, Cardiovascular Disease, Epilepsy, Blood-related disease etc.)
If yes, please identify the condition.
Acknowledgment and Waiver
I acknowledge that a tattoo is a permanent change to my appearance and that no representations have been made to me as the ability to later change or remove my tattoo. To my knowledge, I do not have a physical, mental or medical impairment or disability, which might affect my well being as a direct or indirect result of my decision to have a tattoo. .
I allow my tattoo to be photographed and be used for Tattoo Shop portfolio showcased.
I agree that the studio does not have a way of identifying if I am allergic to the elements or ingredients that will be used for my tattoo.
I understand that I need to take care of the tattoo by following the instructions given to me by the Tattoo artist.
I understand that if I have any skin treatments, laser hair removal, plastic surgery or other skin altering procedures, it may result in adverse changes to my tattoo
I understand that I might get an infection if I don't follow the instructions given to me in regards of taking good care of my tattoo.
I indemnify and hold harmless the Tattoo Shop against any claims, expenses, damages, and liabilities.
I acknowledge I am over the age of 18 and that I have truthfully represented to my tattooer that the obtaining of a tattoo is by my choice alone. I consent to the application of the tattoo and to any actions or conduct of the representative of Black Cat Tattoo reasonably necessary to perform the tattoo procedure
I confirm that the information I provided in this document is accurate and true.
Signed Date
-
Month
-
Day
Year
Date
Client Signature
Please choose an ID type Ie/ Driver's License, Passport or Medical Card. This information is for our records and will never be shared.
*
Drivers License
Passport
Medical Services Card
Provincial ID card
other
ID Number (usually found somewhere on the document)
*
Please provide a photograph of your ID
*
Browse Files
Cancel
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Please indicate if you have received any number of vaccines for Covid-19
*
Yes
No
I have not experienced any cold/flu/covid like symptoms in at least one week (please do not come to your appointment if you are sick. We have too many high risk staff members and will be happy to reschedule your appointment)
*
No symptoms for over a week
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