Medical History Form

Medical History
Full Legal Name*

First NameLast Name
Preferred name
Pronouns*

She/HerHe/HimThey/ThemOther
Birth Date

MonthDayYear
I am of at least 18 years of age*
Phone Number*
Format: (000) 000-0000.
Check all that apply to you*

Latex allergyAllergic to antibioticsFainting or dizzinessDiabetesHIVBlood thinnersEpilepsyAsthmaGonorrhea/SyphilisPregnant or nursingHeart ConditionProne to scarring or keloidingHemopheliaSkin ConditionsMRSA/Staph infectionnone
Do you have any other medical conditions that may interfere with the healing of your tattoo?
Do you use any medications that may interfere with the healing of your tattoo?
Have you had an allergic reaction to tattoo ink before?*

YesNo
BONUS QUESTION: How did you hear about me?
Signature
Should be Empty: