Matt - Consent Form

1

What's your name?* This field is required.

First Name

Last Name

2

What's your address?* This field is required.

Street Address

Street Address Line 2

City

Postal Code

Country

3

What's your email?* This field is required.

We.are@harmless.co.uk

4

What's your date of birth?* This field is required.

Date

5

Please upload a clear photo of your ID. Only passports and driving licenses will be accepted.* This field is required.Required for new clients only. If I have tattooed you before then you can skip this step.

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6

I am over the age of eighteen, and have truthfully represented myself of age.* This field is required.

TrueFalse

7

I have eaten in the last two hours.* This field is required.

TrueFalse

8

I have not consumed drugs or alcohol in the last 24 hours.* This field is required.

TrueFalse

9

I am aware that tattoo process involves the minor breakage of skin with a needle, I understand the health risks and know that I am obliged by law to declare of the following conditions that may affect this procedure.* This field is required.

YESNO

10

Do you have high/low blood pressure?* This field is required.

NoYes

11

Please give more details...

12

Do you have any heart conditions?* This field is required.

NoYes

13

Please give more details...

14

Do you have any conditions that compromise your immune system?* This field is required.

NoYes

15

Please give more details...

16

Do you have any blood-borne viruses? (Hepatitis etc.) * This field is required.

NoYes

17

Please give more details...

18

Do you have any allergies? (Latex, heavy-metals etc)* This field is required.

NoYes

19

Please give more details...

20

Are you Diabetic?* This field is required.

NoYes

21

Please give more details...

22

Do you have any blood clotting disorders?* This field is required.

NoYes

23

Please give more details...

24

Are you pregnant or breast-feeding?* This field is required.

NoYes

25

Please give more details...

26

Do you any form of seizure causing conditions?* This field is required.

NoYes

27

Please give more details...

28

Are you prone to dizziness or fainting?* This field is required.

NoYes

29

Please give more details...

30

I understand that every care has been taken to ensure that this procedure has been carried out in a hygienic manner, and that the aftercare is my sole responsibility.* This field is required.We will go through the aftercare and provide everything you need at the end of the tattoo, and will also email an aftercare guide to you. If you have any questions though, you can always ask!

YESNO

31

I agree to follow any aftercare instructions given to me.* This field is required.Once our job is done it's up to you! Aftercare is extremely important and can drastically affect the quality of the healed tattoo. Please make sure to follow the process as best you can!

YESNO

32

I understand that reaction to the pigments is still possible, even after the tattoo has healed.* This field is required.

YESNO

33

I consent to any actions or conduct necessary to perform the procedure.* This field is required.Depending on the location of the tattoo, your artist may need to lean on your body etc.

YESNO

34

I acknowledge that by signing this agreement, I have been given full and accurate information about the tattoo process and give my full consent to proceed with it.* This field is required.

35

Do you have a fever, or have you felt hot or feverish in the last 14 - 21 days?

YESNO

36

Are you currently experiencing shortness of breath or other difficulties breathing?

YESNO

37

Have you had a recent onset of a new continuous cough?

YESNO

38

Are you currently experiencing any other flu-like symptoms, such as gastrointestinal upset, headache, or fatigue?

YESNO

39

Have you noticed a loss of, or change in, normal sense of taste or smell?

YESNO

40

Are you in contact or have you recently had contact with any confirmed COVID - 19 positive patients?Clients who are themselves well, but who have a sick family member at home are asked to reschedule to a later date, when all members of your household are confirmed healthy.

YESNO

41

Are you or any of your household currently shielding?Clients who are shielding, or have members of their household that are shielding, are advised to reschedule until shielding is over.

YESNO

42

Have you traveled out of the region/country in the past 14 days?

YESNO

43

COVID-19 Liability waiver and contact details for NHS Track and Trace I consent to receive tattoo services during the COVID-19 outbreak. I understand that based on what is currently known about COVID-19, the spread is thought to occur mostly from person to person via respiratory droplets amount close contact. I understand that close contact can occur from being within 2 metres of someone with COVID-19 for a prolonged period or by having direct contact with infectious secretions from someone with COVID-19. I understand that carriers of COVID-19 may not show symptoms but may still be highly contagious. I understand that the symptoms listed below are representative of COVID-19: - High Temperature - Dry cough - A loss or change to sense of smell or taste - Shortness of breath I confirm that I do not display or currently have ANY of the symptoms that are representative of COVID-19, which are outlined above. I confirm, to the best of my knowledge, that I have not had close contact with an individual with these symptoms or diagnosed with COVID-19 in the past 14-21 days. I also confirm that I nor anyone in my household is shielding. I also consent for the artist and studio to hold my contact details for how ever long needed with the sole purpose of aiding the NHS Track and Trace system. This is in addition to other health and safety requirements. I HAVE ANSWERED ALL THESE QUESTIONS HONESTLY AND TO THE BEST OF MY ABILITY. I HAVE NOT IN ANY WAY MISREPRESENTED MY HEALTH STATUS OR THAT OF MY IMMEDIATE HOUSEHOLD IN ORDER TO GET TATTOOED.