Tattoo Consent Form
Client Information
(all starred questions are required before tattoo takes place)
Full Name
*
First Name
Last Name
Age
*
Date of Birth
*
-
Day
-
Month
Year
Date
Phone Number
*
Mobile
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Pre-Procedure Questionnaire
Are you under the influence of drugs or alcohol?
*
Yes
No
FEMALE ONLY: Pregnancy or Nursing?
*
Yes
No
Do you have a communicable disease?
*
Yes
No
Skin conditions (e.g. Rashes, eczema, infection, psoriasis, freckles, 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 understand that this procedure is a permanent change to my skin and body.
*
I allow my tattoo to be photographed and filmed to be used for Tattoo Shop portfolio showcased.
*
I acknowledge that Moth and Flame Tattoo does not offer refund.
*
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 Shop.
*
I understand that I might get an infection if I don't follow the instructions given to me in regards of taking food care of my tattoo.
*
I indemnify and hold harmless the Tattoo Shop against any claims, expenses, damages, and liabilities.
*
I confirm that the information I provided in this document is accurate and true.
Signed Date
*
-
Day
-
Month
Year
Date
Client Signature
*
Submit
Should be Empty: