Informed Medical Consent Form

Data Protection Statement

The information you provided is retained within the hands of Chloé Arros-Steen for a minimum of ten years and may be accessed at any point, years before being destroyed. The information is required for either contact or medical reasons and is never passed on to third parties. This is within the guidelines of the Data Protection Act of 2018.

Full Name*

First NameLast name

Pronouns (do not have to match ID)*

Date of appointment*

Date

Email address*

Contact number*

Home Address

House name or number*

Street*

Town*

Postcode*

Emergency Contact

Fulll Name of Emergency Contact*

First nameLast Name

Relationship to you*

Emergency contact number*

Age*

Date of Birth*

Driving LicencePassportNational ID Card

Please upload a clear photo of you ID document (showing all four corners)*

You have requested a tattoo treatment that involves minor breakage of the skin surface with a needle, and this process may complicate some medical conditions.

Please read the following information carefully, and if any of these conditions apply to you, please discuss them with your practitioner before having your treatment.

If you answer 'Yes' to any of the following questions, your treatment will be reviewed and potentially deferred until medical advice has been obtained, or we will discuss the best way to go about your appointment for your safety.

Do you suffer from any of these conditions?

Rows	Please tick if you hav any of these conditions
High blood pressure
Epilepsy
Heart Disease
Diabetes
Psoriasis
Eczema
Metal Allergy
Adhesive/bandage/plaster Allergy
Low Blood Pressure
PoTs Syndrome
Heart Murmurs
Impetigo
Warts
History of Haemorraging
Hepatitis
Haemophilia or ITP
Pace Maker
Latex Allergy
Long Covid
Cancer

YesNo

If yes, please describe below.

YesNo

If yes, please add details below and also add any support I can provide to make your experience better.

YesNo

Declaration*

Rows	Please tick all
I hereby declare that I give my full consent to the tattoo being carried out by Chloé Arros.
I confirm that I have discussed my tattoo design and have approved the project. I would like to proceed with the tattoo.
I acknowledge that variations in colour and design may exist between any tattoo selected by me and ultimately applied to my body. I also understand that overtime, my tattoos' colours and clarity will fade due to unprotected exposire to the sun and the naturally occurring dispersion of pigment under the skin. I understand that the tone of my skin will control the outcome of the overall colour of my tattoo.
I understand a tattoo is a permanent change to my appearance and can only be removed by laser or surgical means, which can be disfiguring and/or costly and which in all likelihood will not result in the full restoration of my skin to its exact appearance before it was tattooed.
I acknowledge possible complications, e.g., swelling or infection, could happen as a result of obtaining a tattoo, particularly in the event I do not take proper care of my tattoo. I agree to take the risk that such a reaction is possible.
I agree that any touch up needed due to my own negligence or unwillingness to follow the artist's aftercare recommendations will be done at my own expense.
I acknowledge it is not reasonably possible for the artist to determine whether I might have an allergic reaction to the pigments or processes used for the tattoo. I agree to take the risk that this is a possible reaction. I have discussed known allergies with my artist.
I agree to allow photographs or video of my tattoo taken by the artist to be used online for media and advertising. My presence in the studio may be shared. I have discussed with the artisr if this is a concern.
I confirm that the information provided by me in the consent form is correct to the best of my knowledge and that I am over the age of consent for this procedure (18 years old).

Informed Medical Consent Form

Personal Information

ID Check

Medical Review