Tattoo Consent Form
*To be completed on the day of your appointment!*
Client Information
Name
*
First Name
Last Name
Age
*
Birth Date
*
-
Month
-
Day
Year
Date
Phone Number
*
Email
example@example.com
Address
*
Street Address
Street Address Line 2
City
County
Postal / Zip Code
Pre-Procedure Questionnaire
Are you under the influence of drugs or alcohol?
*
Yes
No
Are you pregnant or nursing?
*
Yes
No
Are you on any medication?
*
Yes
No
If yes, please explain further.
If yes, please identify the condition.
Do you have any allergies?
*
Yes
No
If yes, please explain further.
If yes, please identify the condition.
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.
Do you have any of the following?
Heart Disease/Condition
Impetigo
Seizure/Epilepsy
HIV Infection
High or Low Blood Pressure
Cellulitis
Immuno-suppresion
Haemophilia
Eczema
Haemorrhaging
Diabetes
Hepatitis A/B/C
Eating Disorder
Psoriasis
Allergic Responses
If yes to any of the above, please tell about your medical history.
If yes, please identify the condition.
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 Tattoo Shop portfolio and social media.
*
I acknowledge that I am over the age of 18.
*
I acknowledge that the Tattoo Shop does not offer refund.
*
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 and I understand that I might get an infection if I don't follow the instructions given to me in regards of taking care of my tattoo.
*
I acknowledge that I am not pregnant or nursing.
*
I indentify 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
Should be Empty: