IIMMERSE TATTOO CONSENT FORM
Client Information
Name
*
First Name
Last Name
Age
*
Birth Date
*
-
Month
-
Day
Year
Date
Phone Number
Format: (000) 000-0000.
Email
example@example.com
Address
*
Street Address
City
State / Province
Postal / Zip Code
Pre-Procedure Questionnaire
Have you ever received a professional tattoo before?
*
Yes
No
Are you over 18?
*
Yes
Are you under the influence of any drugs or alcohol?
*
Yes
No
Have you eaten in the last 4 hours?
*
Yes
No
Have you taken any aspirin, ibuprofen, or blood thinners in the last 24 hours?
*
Yes
No
Are you prone to fainting?
*
Yes
No
Are you prone to heavy bleeding?
*
Yes
No
Do you have any allergies?
*
Yes
No
If yes, please specify
Are you currently on any medications?
*
Yes
No
If yes, please specify
Are you pregnant or breastfeeding?
*
Yes
No
Do you have any communicable diseases? (H.I.V., A.I.D.S., HEPITITIS)
*
Yes
No
Do you have any other conditions which might affect the healing of this tattoo?
*
Yes
No
Acknowledgment and Waiver
Please tick all boxes below
*
I understand the risks (known and unknown) involved in receiving a tattoo and in doing so release the tattoo studio, the tattoo artist and any employees from all manner of liabilities, claims, actions and demands, in law or in equity.
*
I understand I will be tattooed using appropriate instruments and techniques. I understand there is full aftercare instructions online at www.IIMMERSE.com.au.
*
I assume full responsibility for aftercare and cleanliness and understand that any touch-up work needed due to my own negligence will be done at my own expense.
*
I willingly submit to these procedures with a full understanding of possible complications such as, but not limited to infection, allergic reaction, or rejection of the ink.
*
I confirm that the information I provided in this document is accurate and true.
*
I agree and consent to the pricing of 200ph from stencil placement time. I understand day rates are capped $1300. Tattoos palm size and below may be priced by piece. All appointments require 5 days notice to reschedule and deposits are non refundable.
Signed Date
-
Month
-
Day
Year
Date
Client Signature
Submit
drivers licence number
Should be Empty: