Tattoo Consent Form

Tattoo Consent Form

Please complete this form to the best of your knowledge. Thank you.
Name*

First NameLast Name
Appointment Date*

DayMonthYear
Email*
example@example.com
Phone Number*
Address*

Street Address

Street Address Line 2

Town / CityState / Province

Postcode
Date of Birth*

DayMonthYear
If you are under 21, please add an image of your photo ID.

Eg. Your driving licence, passport or a student card.
Cancelof
Your GP surgery name and town/city*
Emergency Contact Name*
Emergency Contact Phone Number*
Short Description of Tattoo + Placement*
Do you have any of the following conditions? Please tick all that apply.

AllergiesDiabetesHepatitisHeart ConditionHigh or Low Blood PressureHaemophilia or other bleeding disordersCancerEpilepsyHIV or other auto-immune conditionsSkin diseases or conditions on the area to be tattooed, including psoriasis, eczema or acneSensitivity or allergy to medical adhesiveOther conditions that may affect treatment or healingAre you on medication that makes the skin hypersensitive, thins the blood, or compromises the immune system or healing?Sensitivity or allergy to latex
If you ticked any of the above boxes, please give relevant details.
Please indicate that you agree to each of the following:
Do you consent to images and videos of your tattoo being shared on social media?*

YesNo
If you ticked yes, please share your Instagram username below.
Client Signature*

Clear
Today's Date*

DayMonthYear
Date
Should be Empty: