Consent Form

Consent Form

Les Tattoos
Client Information

Please fill out the following boxes
Name*

First NameLast Name
Date of birth *

MonthDayYear
Today’s date

MonthDayYear
Date
Phone Number

Area codePhone Number
Preferred Pronouns
Is this a touch up?
1 hour2 hours3-4 hours5-6+
Procedure
Tattoo/Permanent Cosmetics/ToothGems
Artist*
Mari, Void, Aliyha, Baylie, Alex, Mo, Talula, Cynthia, guest artist
Have you gone to this artist before?
Procedure Details

Please answer the following questions.
Have you or anyone you know been diagnosed or have had any symptoms of COVID-19 in the last two weeks?*
If yes, then please specify it on the field above.
List any of the following conditions that may apply to you: allergic to antibiotics, allergic to latex, asthma, blood thinners, diabetes, eczema/psoriasis (if so, is it in the area you are getting tattooed), epilepsy, fainting/dizziness, gonorrhea/syphilis, heart condition, hemophilia, hepatitis, herpes, HIV, mrsa/staph infection, scarring/keloiding, skin conditions, other: *
If yes, then please specify it on the field above.
Do you have allergies to metals, soaps, cosmetics or alcohol?*
If yes, then please specify it on the field above.
Are you currently taking any medications/antibiotics?*
If yes, then please specify it on the field above.
Do you use any medications that may affect the healing of the body art you wish to receive?*
If yes, then please specify it on the field above.
Do you have any cardiac valve disease?*
If yes, then please specify it on the field above.
Do you have any allergies to adhesive tape, medical tape or second skin (saniderm)?*
If yes, then please specify it on the field above.
Do you have high blood pressure?*
If yes, then please specify it on the field above.
Do you have any medical conditions that we should be aware of? (Communicable disease, cardiovascular problems, diabetes, etc.)*
If yes, then please specify it on the field above.
Do you have difficulties stopping bleeding?*
If yes, then please specify it on the field above.
Have you consumed any food in the last 2 hours?*
If yes, then please specify it on the field above.
Have you consumed any alcohol in the last 8 hours?*
If yes, then please specify it on the field above.
Have you consumed any anticoagulants in the past 24 hours? (aspirin, ibuprofen, etc.)*
If yes, then please specify it on the field above.
Are you pregnant?*
If yes, then please specify it on the field above.
Are you on accutane ?*
If yes, then please specify it on the field above.
Acknowledgment and Waiver

I acknowledge by signing this release form that I have been given the full opportunity to ask any and all questions I might have about obtaining a tattoo from LES TATTOOS. I acknowledge that all my questions have been answered to my full and total satisfaction. I specifically acknowledge that I have been advised of the facts and matters set forth below, and I agree as follows: I am not under any influence of alcohol or drugs. I do not have acne, freckles, moles, or sunburn in the area to be tattooed that might be agitated by the tattoo process (healing included). I have looked over my design, checked to ensure spelling is correct, and give my full consent to the application of my tattoo. I acknowledge that I am not pregnant. I acknowledge that I am free of all spreadable diseases. I acknowledge that I have fully represented to the associates, agents, and representatives of LES TATTOOS that I am over the age of 18 years old. I acknowledge it is not reasonable or possible for the associates, agents or representatives of LES TATTOOS to determine whether I might have an allergic reaction to the dyes, pigment, or process used in my tattoo and I agree to accept that such risks are possible. I acknowledge that infection is always possible as a result of obtaining a tattoo, particularly in that event that I do not take proper care of my tattoo, and I have been advised of the signs and symptoms of infection that indicate you need to seek medical care. I acknowledge receipt of written instructions advising me of all proper care of my tattoo and recognize the absolute necessity of following those written instructions. All questions about the body art procedure have been answered to my satisfaction. I acknowledge that variations in color and design may exist between any tattoos as selected by me and as ultimately applied to my body. I acknowledge that tattooing is a permanent change of my body and that no representations have been made to me as to the ability to later change, alter or remove my tattoo. I acknowledge that the obtaining of my tattoo is my choice alone and I consent to the application of the tattoo and to any actions or contact or conduct associates, agents , or representation says of LES TATTOOS that are reasonably necessary to perform the tattoo procedure. I agreed to release and forever discharge and forever hold harmless LESTATTOOS and it’s associates, agents of officer and shareholders from any and all claims damages or legal action arising from or connected in anyway with my tattoo where the procedures and conduct use to apply my tattoo any and all tattoo applied by LES TATTOOS and it’s associates, agents, and representatives in the future. I acknowledge tattoo ink, dyes, and pigments have not been approved by the federal food and drug administration and the health consequences of using these products are unknown. If there is a thought that there is a chance I might feel lightheaded/ dizzy during or after being tattooed I agree to immediately notify the practitioner in the event I feel lightheaded ,dizzy, or faint before, during, or after the procedure. I agreed to the follow all instructions concerning the care of my tattoo and that any touch ups needed because of my own negligence will be done at my own expense.
I allow and authorize (LES TATTOOS) to perform this procedure to me.I have been fully informed of the rest of tattooing including but not limited to infections, scarring, difficulties in detecting melanoma and allergic reaction to tattoo pigment, latex glove, and antibiotics. Having been informed of the potential risk associated with getting a tattoo or permanent cosmetic, I still wish to proceed with tattoo application and I assume any and all risks that may arise from tattooing fall under my care.I acknowledge that all information I provided in this form is true and accurate.
Patient Signature*

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Please upload a picture of your photo ID here.
Signed Date

MonthDayYear
Lot numbers/ per each needle used
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Consent Form

Client Information

Procedure Details

Acknowledgment and Waiver