Chakra Tattoos Consent Form
Client Information
Full Name
*
First Name
Last Name
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
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.
Allergies (Food, Medication, Latex, etc.)
If yes, please identify the allergies you have.
Is this is your first tattoo?
*
Yes, this is my first tattoo
No, Ive been tattooed before
Do you allow any photographs/video taken by the artist to be used for media advertising such as but not limited to; social media outlets, newspaper, commercials, tv, flyer ads, website, portfolio displays, other marketing materials, etc?
*
Yes
No
Acknowledgment and Waiver
*
I acknowledge that social distancing due to COVID-19 while getting tattoos is impossible.
*
I acknowledge I am healthy and have not been in contact with anyone who has been sick within 24 hrs of this appointment.
*
If I have diabetes, epilepsy, hepatitis, hemophilia, HIV-AIDS, or any other communicable disease, heart condition or take medicine which thins the blood I have advised my tattooist. I am not pregnant or nursing. I am not under the influence of alcohol or drugs.
*
I do not have medical or skin conditions such as but not limited to: acne, scarring (Keloid), Eczema, psoriasis, freckles, moles or sunburn in the area to be tattooed that may interfere with said tattoo. If I have any type of infection or rash anywhere on my body, I will advise my tattooist.
*
I acknowledge it is not reasonably possible for the representatives and employees of this tattoo shop to determine whether I might have an allergic reaction to the pigments or processes used in my tattoo, and I agree to accept the risk that such a reaction is possible.
*
I acknowledge that infection is always possible as a result of the obtaining of a tattoo, particularly if I do not take proper care of my tattoo. I have received aftercare instructions and I agree to follow them while my tattoo is healing. I agree that any touch-up work needed, due to my own negligence, will be done at my own expense.
*
I realize that variations in color and design may exist between any tattoo as selected by me and as ultimately applied to my body. I understand that if my skin color is dark, the colors will not appear as bright as they do on light skin.
*
I acknowledge that a tattoo is a permanent change to my appearance and that no representations have been made to me as to 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 acknowledge I am over the age of eighteen and that I have truthfully represented to my tattooist 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 representatives and employees of the tattoo shop reasonably necessary to perform the tattoo procedure.
*
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.
Signed Date
*
-
Month
-
Day
Year
Date
Client Signature
*
Please upload Photo I.D
*
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