Dark Bloom Tattoo Consent Form

Dark Bloom Tattoo Consent Form
Client Information
Name

First NameLast Name
Age
Birth Date

MonthDayYear
Date
Phone Number
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Front of ID
Back of ID
Pre-Procedure Questionnaire
Are you under the influence of drugs or alcohol?

YesNo
FEMALE ONLY: Are you pregnant or nursing?

YesNo
Do you have a communicable disease?

YesNo
Do you have any skin conditions?

YesNo
Skin conditions (e.g. Rashes, eczema, infection, psoriasis, freckles, etc.)
If yes, please identify the condition.
Acknowledgment and Waiver
Please tell about your medical history (e.g. DIabetes, Cardiovascular Disease, Epilepsy, Blood-related disease etc.)
If yes, please identify the condition.
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 showcased.
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.
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

MonthDayYear
Date
Client Signature

Clear
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

Clear
Date of Procedure

MonthDayYear
Date
Address of Tattoo Establishment

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Should be Empty:

Dark Bloom Tattoo Consent Form

Client Information

Pre-Procedure Questionnaire

Acknowledgment and Waiver