Ink Shrink Tattoo
Consent form
Client Information
Name
*
First Name
Last Name
Age
*
Birth Date
*
-
Month
-
Day
Year
Date
ID Type
*
Ex: CO drivers license, passport, military ID, etc.
ID Number
*
Phone Number
*
Format: (000) 000-0000.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Pre-Procedure Questionnaire
Date of Procedure
-
Month
-
Day
Year
Date
Description of tattoo
Image, size, location
Are you under the influence of drugs or alcohol?
*
Yes
No
Are you pregnant or nursing?
*
Yes
No
Do you have a communicable disease?
*
Yes
No
Do you have any skin conditions?
*
Yes
No
Skin conditions (e.g. Rashes, eczema, infection, psoriasis, freckles, etc.)
If yes, please identify the condition and inform tattooist.
Please tell about any important medical history (e.g. Allergies, diabetes, Cardiovascular Disease, Epilepsy, Blood-related disease etc.)
If yes, please identify the condition and inform tattooist.
Acknowledgment and Waiver
*
I understand that this procedure is a permanent change to my skin and body.
*
I allow my tattoo to be photographed and be used for Paige’s promotional material.
I do NOT allow my tattoo to be photographed and be used for Paige’s promotional material.
*
I acknowledge that the Ink Shrink Ltd. does not offer refunds.
*
I agree that the studio does not have a way of identifying if I am allergic to the elements or ingredients that will be used for my tattoo.
*
I understand that I need to take care of the tattoo by following the instructions given to me by the Tattoo Shop.
I understand I have the right to stop the procedure
*
I understand that I might get an infection if I don't follow the instructions given to me in regards of taking good care of my tattoo.
*
I indemnify and hold harmless the Tattoo Shop against any claims, expenses, damages, and liabilities.
*
I confirm that the information I provided in this document is accurate and true.
Signed Date
*
-
Month
-
Day
Year
Date
Client Signature
*
Submit
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