Tattoo Consent Form
Grace Avery Tattoo
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
Govenment-Issued ID # (Driver's license etc.)
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Appointment Date
COVID-19
Have you, or anyone you have been in contact with tested positive for COVID-19 within the past 14 days?
Yes
No
Have you, or anyone you have recently been in contact with traveled outside of the country within the past 14 days?
Yes
No
Pre-Procedure Questionnaire
Have you eaten a meal within the past 4 hours at the time of the appointment beginning?
Yes
No
Pregnant or Nursing? If so, the appointment must be rescheduled at a later date.
Yes
No
Do you have any bloodeborne diseases?
Yes
No
Skin conditions (e.g. Rashes, eczema, infection, psoriasis, freckles, etc.)
If yes, please identify the condition.
Relevant Medical History (e.g. DIabetes, Cardiovascular Disease, Epilepsy, Blood-thinning medications etc.)
If yes, please identify the condition.
Acknowledgment and Waiver
Medical
I do not have diabetes, epilepsy, hemophilia, nor do I take blood thinning medication. I do not have any other medical which may affect the healing of the tattoo or increase my risk of complications during the tattoo procedure. I am not the recipient of an organ or bone-marrow transplant, or if I am, I have taken the appropriate preventative antibiotics. I do not have any mental impairment which will affect my judgement in choosing to get the tattoo.
Sobriety and consent
I am not currently under the influence of alcohol or drugs and am prepared to complete my tattoo appointment of my own consent, and I have not been coerced and am not under duress.
Permanent
I understand that this procedure is a permanent change to my skin and body.
Photography
I allow my tattoo to be photographed and be used for Tattoo Shop portfolio showcased.
No Refunds
I acknowledge that the Tattoo Shop does not offer refunds
Allergies
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.
Aftercare
I understand that I need to take care of the tattoo by following the instructions given to me by the Tattoo Shop.
Risk of Infection
I understand that there is always the risk of an infection after getting a tattoo, and that this risk is increased if I do not follow the tattoo artist's aftercare instructions. I will not hold the tattoo artist or studio responsible for any infections which may occur and will seek appropriate follow-up care, potentially including medical intervention in the case of a suspected infection.
Fading
I understand that the colors and clarity of my tattoo will change and fade over time, and that this is a natural process which cannot be prevented by the tattoo artist.
Questions
I acknowledge that I have been given adequate opportunity to ask any relevant questions that I have in regard to the tattoo procedure and healing process.
Spelling
The tattoo artist is not responsible for the correct spelling or translation of any text in any tattoo, or for confirming the meaning of any symbol appearing in any tattoo.
Legal Action
I indemnify and hold harmless the Tattoo Shop against any claims, expenses, damages, and liabilities. I agree to pay the shop and artists' legal fees incurred in the course of any legal action in which either the artist or the tattoo studio is the prevailing party. I agree that the courts of Alberta shall have exclusive jurisdiction for the purpose of litigating any dispute arising from or relating to this agreement.
Payment
I agree and understand that I can pay CASH or DEBIT only for my tattoo and that GST will be added to the final tattoo price.
Confirmation of accuracy
I confirm that the information I provided in this document is accurate and true.
Signed Date
-
Month
-
Day
Year
Date
Client Signature
Clear
Submit
Should be Empty: