Intake Form
Everything must be completed.
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Format: (000) 000-0000.
E-mail
example@example.com
I am 18 years or older
Yes
No
Are you prone to fainting?
Yes
No
Do you have any of the following?
Alopecia
Autoimmune disease
Bleeding disorder
Cancer
Diabetes
Heart related problems
Hepatitis
High Blood pressure
Hives or skin rash
None
Other
Do you have any conditions that might affect the healing of the tattoo?
Yes
No
If you answered yes to the above question, please explain:
Do you have any known food or drug allergies?
Yes
No
If you answered yes to the above question, please list below:
Do you have a history of cold sores?
Yes
No
Are you pregnant? (Women)
Yes
No
Are you nursing? (Women)
Yes
No
Are you currently taking any medications or over the counter supplements?
Yes
No
If you answered yes to the above question, please list: (including blood thinners, chemo treatment, biologics, and/or over the counter supplements)
Signature
Submit
Should be Empty: