Tattoo Consent Form

Tattoo Consent Form
Client Information
Full Name*

First NameLast Name
Age*
Date of Birth*

MonthDayYear
Date
Phone Number*

Area CodePhone Number
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Pre-Procedure Questionnaire
Are you under the influence of drugs or alcohol?*

YesNo
Pregnancy or Nursing?

YesNo
Do you have a communicable disease?*

YesNo
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 be used for Tattoo Shop portfolio showcased.
I acknowledge that the Tattoo Shop 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 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*

MonthDayYear
Date
Client Signature*

Clear
Take Photo of your Drivers License/ID*
If you have any questions please contact me... - text 661-431-9466

Third Energy Tattoo

3401 Chester ave suite F

Bakersfield California

93312
Should be Empty:

Tattoo Consent Form

Client Information

Pre-Procedure Questionnaire

Acknowledgment and Waiver