Tattoo Consent and Release Form

Tattoo Consent and Release Form

Three Hounds Tattoo, Lorin A Devine LLC
Photo ID*

Cancelof
Take a picture of your ID*
Legal Name*

First NameLast Name
Pronouns: blanks
Ex.; They/them, she/her, he/they, etc.
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please note, you cannot be tattooed at this time if any of the following apply:
- You are under the age of 18.
- You are Pregnant or Breast-feeding.
- You are undergoing chemotherapy. (a doctor’s note must be provided)
- You have any legions, moles, blemishes, hair transplants, are sunburnt or have any other irregularities on the intended area.
- You have been on Accutane within the last year.
- You are under the influence of alcohol or drugs.
- You have been tanning or sunburned in the procedure area in the last 30 days.
- If you are sick or have been on antibiotics in the last 30 days
DiabetesHemophilia (history of bleeding disorders)Psoriasis or EczemaCold Sores and/or Fever BlistersPregnant or nursing (breast feeding)Epilepsy
Please describe any other medical issues, skin conditions, history of adverse reactions to tattoo procedures, or diseases that may affect your tattoo services:
List any sensitivities to medications or topical solutions:
I confirm (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any pertinent information that may be relevant to the tattoo procedure and will advice Lorin A Devine LLC of any health changes.

Tattoo Consent and Release Form

Pre-Procedure Questionnaire

Acknowledgement and Waiver