You can always press Enter⏎ to continue
Welcome
Hi there, please fill out and submit this form.
41
Questions
START
1
Legal Name
*
This field is required.
First Name
Last Name
Previous
Skip
Submit
Press
Enter
2
Preferred Name
If different
First Name
Last Name
Previous
Skip
Submit
Press
Enter
3
Pronouns
Previous
Skip
Submit
Press
Enter
4
Birthdate
*
This field is required.
-
Date
Year
Month
Day
Previous
Skip
Submit
Press
Enter
5
Phone Number
*
This field is required.
Please enter a valid phone number.
Previous
Skip
Submit
Press
Enter
6
Do you have any of the following medical conditions?
*
This field is required.
Check ALL that apply
HIV
Hepatitis
TB
Herpes
Diabetes
Asthma
Epilepsy
Skin conditions
Blood Thinners
Hemophilia
Eczema/Psoriasis
Heart Conditions
Gonorrhea
Syphilis
Latex Allergies
MRSA/ Staph
Pregnant/Nursing
Fainting/Dizziness
Scarring/Keloiding
Antibiotic Allergies
NONE OF THESE
Other
Previous
Skip
Submit
Press
Enter
7
Do you have a history of herpes at the procedure site?
*
This field is required.
YES
NO
Previous
Skip
Submit
Press
Enter
8
Do you have any cardiac valve disease?
*
This field is required.
YES
NO
Previous
Skip
Submit
Press
Enter
9
Do you have any other risks for blood borne pathogens exposure?
*
This field is required.
ie- working in the medical field etc.
Previous
Skip
Submit
Press
Enter
10
Do you have any additional allergies such as to metals, soaps, cosmetics or alcohol?
*
This field is required.
Previous
Skip
Submit
Press
Enter
11
Do you use any medications that might affect the healing of the body art you wish to receive?
*
This field is required.
Previous
Skip
Submit
Press
Enter
12
Do you have a history of medication use or are you currently using medication, including being prescribed antibiotics prior to dental or surgical procedures?
*
This field is required.
Previous
Skip
Submit
Press
Enter
13
Is there any information that you feel you should provide to the body art practitioner?
*
This field is required.
Previous
Skip
Submit
Press
Enter
14
In consideration of receiving BODY ART from the practitioner at VELVET ORANGE BODYCRAFT (together with its employees, it’s apprentices, and agents, the “Body Art Business”) I confirm the following by initialing each applicable item:
*
This field is required.
I am the person on the legal ID presented as proof that I am at least 18 years of age
Clear
Previous
Skip
Submit
Press
Enter
15
*
This field is required.
I am not under the influence of alcohol or drugs and that I am voluntarily submitting myself to receive body art without duress or coercion.
Clear
Previous
Skip
Submit
Press
Enter
16
*
This field is required.
I acknowledge that the information that I have provided in the medical questionnaire is complete and true to the best of my knowledge.
Clear
Previous
Skip
Submit
Press
Enter
17
*
This field is required.
I understand the permanent nature of receiving body art and that removal can be expensive and may leave scars on the procedure site.
Clear
Previous
Skip
Submit
Press
Enter
18
*
This field is required.
The body art described or shown on the client record form is correctly placed to my specifications.
Clear
Previous
Skip
Submit
Press
Enter
19
*
This field is required.
All questions about the body art procedure have been answered to my satisfaction, and I have been given written aftercare instructions for the procedure I am about to receive.
Clear
Previous
Skip
Submit
Press
Enter
20
*
This field is required.
I understand there are restrictions on physical activities such as bathing, recreational water activities, gardening, and contact with animals for 6 weeks
Clear
Previous
Skip
Submit
Press
Enter
21
*
This field is required.
I understand that any medical information obtained will be subject to the federal Health Insurance Portability and Accountability Act of 1996 (HIPPA).
Clear
Previous
Skip
Submit
Press
Enter
22
*
This field is required.
I am aware of the signs and symptoms of infection, including, but not limited to redness, swelling, tenderness of the procedure site, red streaks going from the procedure site towards the heart, elevated body temperature, or purulent drainage from the procedure site.
Clear
Previous
Skip
Submit
Press
Enter
23
*
This field is required.
I understand there is a possibility of getting an infection as a result of receiving body art particularly in the event that I do not take proper care of the procedure site.
Clear
Previous
Skip
Submit
Press
Enter
24
*
This field is required.
I will seek professional medical attention if signs and symptoms of infection occur.
Clear
Previous
Skip
Submit
Press
Enter
25
*
This field is required.
I agree to follow all instructions concerning the care of my tattoo or piercing, and that any touch-ups needed due to my own negligence will be done at my own expense.
Clear
Previous
Skip
Submit
Press
Enter
26
*
This field is required.
I understand that there is a chance I might feel lightheaded, dizzy during or after being tattooed or pierced.
Clear
Previous
Skip
Submit
Press
Enter
27
*
This field is required.
I agree to immediately notify the artist in the event I feel lightheaded, dizzy and/or faint before, during or after the procedure.
Clear
Previous
Skip
Submit
Press
Enter
28
*
This field is required.
I understand that physical distancing will not be possible during this procedure and that by undergoing this procedure I may increase my risk of contracting pathogens including but not limited to COVID-19.
Clear
Previous
Skip
Submit
Press
Enter
29
I am aware that tattoo inks, dyes, and pigments used on the procedure site have not been approved by the federal Food and Drug Administration, and that the health consequences of using these products are unknown.
*
This field is required.
Clear
Previous
Skip
Submit
Press
Enter
30
I have reviewed and confirmed the design of my body art including but not limited to; placement, size, color(s), dates and spellings.
*
This field is required.
Clear
Previous
Skip
Submit
Press
Enter
31
I have reviewed and confirmed any and all numbers, letters, characters or symbols used in the design of my body art.
*
This field is required.
Clear
Previous
Skip
Submit
Press
Enter
32
I understand that the Body Art Facility shall have no liability for errors including but not limited to misspellings or incorrect dates, meanings and translations.
*
This field is required.
Clear
Previous
Skip
Submit
Press
Enter
33
I have been fully informed of the risks of body art including but not limited to infection, scarring, difficulties in detecting melanoma, and allergic reactions to tattoo pigment, latex gloves, and antibiotics. Having been informed of the potential risks associated with a body art procedure, I still wish to proceed with the body art application and I assume any and all risks that may arise from body art.
*
This field is required.
Clear
Previous
Skip
Submit
Press
Enter
34
I have received Aftercare Instructions
*
This field is required.
Clear
Previous
Skip
Submit
Press
Enter
35
Today’s Date
-
Date
Year
Month
Day
Previous
Skip
Submit
Press
Enter
36
Practitioner
*
This field is required.
Delia
Chad
Delia
Chad
Previous
Skip
Submit
Press
Enter
37
Identification
ID/DL
Birth Certificate
Passport
Tribal ID
Other
Previous
Skip
Submit
Press
Enter
38
Tattoo Location
*
This field is required.
Previous
Skip
Submit
Press
Enter
39
Tattoo Description
*
This field is required.
Previous
Skip
Submit
Press
Enter
40
To the best of my knowledge this information is correct
*
This field is required.
Clear
Previous
Skip
Submit
Press
Enter
41
Needle Packets
*
This field is required.
Drag and drop files here
Select files to upload
Max. file size
: 10.6MB
Browse Files
Cancel
of
Previous
Skip
Submit
Press
Enter
Should be Empty:
Question Label
1
of
41
See All
Go Back
Submit