Dark Bloom Tattoo Consent Form

Name

First NameLast Name

Age

Birth Date

Date

Phone Number

Format: (000) 000-0000.

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Front of ID

Back of ID

Are you under the influence of drugs or alcohol?

FEMALE ONLY: Are you pregnant or nursing?

Do you have a communicable disease?

Do you have any skin conditions?

Skin conditions (e.g. Rashes, eczema, infection, psoriasis, freckles, etc.)

If yes, please identify the condition.

Please tell about your medical history (e.g. DIabetes, Cardiovascular Disease, Epilepsy, Blood-related disease etc.)

If yes, please identify the condition.

Type a question

Signed Date

Date

Client Signature

AFFIDAVIT OF TATTOOIST:

I declare that I am the tattooist referred to on this form and performing the tattooing procedure on the patron as indicated above. I further declare that I have reviewed the information provided by the patron on this form prior to performing any tattooing procedure. I understand that failure to comply with the statutes and/or administrative code provisions of the licensing authority will be cause for license discipline and/or further legal action. By signing below, I am signifying that I have read the above statements and understand the obligation I have as a tattooist.

Name of Tattoo Artist

First NameLast Name

Signature of Tattoo Artist

Date of Procedure

Date

Address of Tattoo Establishment

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Dark Bloom Tattoo Consent Form

Client Information

Pre-Procedure Questionnaire

Acknowledgment and Waiver