TRACK AND TRACE FORM TO BE COMPLETED UP TO 48 HOURS BEFORE APPOINTMENT
Ultimate Inc Limited, Pontypridd, CF37 1BE 01443 401222 & The Ultimate Inc Private Tattoo Studio, Pontypridd CF37 1RS
Client Information
Full Name
*
First Name
Last Name
Age
*
Age
Date Of Birth (full year dd-mm-yyyy)
If under 16 years of age legal guardian for consent
First Name
Last Name
Phone Number
*
-
Area Code (+44) or (0)
Phone Number
Address
*
Address
Address
Town
County
Post Code
Pre-Procedure Questionnaire
Do you have a skin condition?
*
Yes
No
Skin conditions (e.g. Rashes, eczema, infection, psoriasis, freckles, etc.)
*
Type none or If yes, please identify the condition.
Medical History (e.g. DIabetes, Cardiovascular Disease, Epilepsy, Blood-related disease etc.)
*
Type none or If yes, please identify the condition.
Consent and COVID-19 Waiver
By checking the boxes, you confirm that you agree with the following statement:
*
i understand that i have a risk of contracting a virus during this service, I agree to follow the studio rules during my appointment in order to minimize the spread of viruses, i have not been diagnosed with COVID-19 in the last 14 days, i am not waiting for laboratory results for COVID-19
Click this box if you DO NOT you have any of the following symptoms?
*
cough, shortness of breath, high fever, muscle pain, body ache, or loss of taste or smell, I have not been in contact with anyone that has Covid-19 symptoms and i am not living with anyone who is self isolating due to CORONA-19.
I CONFIRM THAT
*
I understand that the tattooing / piercing procedure is a permanent change to my skin and body,.
I CONFIRM THAT
*
i am aware that cctv is used throughout both studios with recording audio and video for the purpose of crime prevention and customer safety, I am aware that a privacy screen is available on my request for intermate tattoos and piercings if i wish to use them , I also confirm that i allow my tattoo and or piercings to be photographed and i give my consent that they may be used for This tattoo and piercing studios portfolio and For use in advertising / social media.
I CONFORM THAT
*
I acknowledge that if I am later or my appointment / come for my treatment under the influence or drugs or alcohol I will not be treated and will forfeit my deposit in full, if I want to rebook my appointment then I will pay the full amount as a deposit.
I CONFIRM THAT
*
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 and or piercings and I give my full consent to be treated at my own risk.
I CONFIRM THAT
*
I understand that it is my responsibility to take care of the tattoo and or piercings by following the instructions given to me by the Tattoo Studio., I will not hold this tattoo studio responsible for my negligence.
I CONFIRM THAT
*
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 / piercing.
I CONFIRM THAT
*
I indemnify and hold harmless the Tattoo Studio and all employees of this studio against any claims, expenses, damages, and liabilities. I also confirm that guest tattoo artists whom rent chair space from ultimate inc limited are independent self employed tattoo artists whom are responsible for there own public and treatment liabilities, i will not hold Ultimate inc limited responsible for any treatment if i get tattooed by any guest tattoo artists at this studio.
I CONFIRM THAT
*
I the client (or the legal guardian consenting for the child) are of the legal age for the relevant treatment and the information I provided in this document is accurate and true.I WILL BRING PHOTO ID ON EVERY VISIT FOR TREATMENT, if I do not bring my PHOTO ID then I will not be treated and forfeit any deposit paid.
Signed Date
*
-
Day
-
Month
Year
Date - dd-mm-yyyy (full year)
Client Signature
*
Submit
Should be Empty: