BROWTOURAGE - Tattoo - Consent Form

Confidential Medical Profile and Tattoo Release Form
Name*
Date Of Birth*

MonthDayYear
Date
Address*
To avoid unforeseen complications, please answer the following questions:
Are you 18 years old or older?*

YesNo
If not 18 years old or older, guardians initials
Are you pregnant or nursing?*

YesNo
Are you allergic to any metal?*

YesNo
Have you had any aspirin or blood thinners in the past week?*

YesNo
Have you ever had any Tattoo procedures before?*

YesNo
Have you had any mood altering drugs within the last 8 hours?*

YesNo
Are you on any immuno-suppressive medications such as anti-infiammatories or steroids?*

YesNo
Do you have a history of cold sores, herpes, or fever blisters?*

YesNo
Are you allergic to topical antibiotic preparations or de-sensitizers?*

YesNo
Are you sensitive/allergic to latex?*

YesNo
Is there any history of skin diseases or remarkable skin sensitivities?*

YesNo
Are you ready to get your Tattoo today?*

YesNo
Are you currently undergoing Radiation or Chemotherapy?*

YesNo
Are you required to take Antibiotics during Dental or Invasive Medical procedures?*

YesNo
Previous problems with tattoos or has your physician advised you not to have a tattoos at this time?*

YesNo
List all, or any medications you are currently taking.

Please check mark any of the following medical conditions which may pertain to you:

	I have the following medical conditions
Heart Conditions
Allergies to Makeup
Accutane Treatment
Dry Eyes
Diabetes
Stroke
Chest Pains
Alopecia
Refractive Eye Surgery
Glaucoma
Trichotillomania
Keloids/Hypertrophy Of Scars
Epilepsy/Seizures
Shortness Of Breath
Autoimmune Disorder
Cancer (Any)
Hepatitis/ Jaundice
HIV
Kidney Disease
Tendency To Develop Fever
Blisters On The Lip
Ocular Herpes
Hyperpigmentation
Hypopigmentation
Tendency To Bleed Excessively From Minor Injuries

Read and Check All The Boxes*

I have truthfully represented to the associates, agents, representatives of BrowTourage that I am eighteen (18) years of age or older, have no guardian or committee appointed for me by any court anywhere and am competent and make this release.I understand that it is not reasonably possible for the associates, agents, representatives of BrowTourage to determine whether I might have any allergic reaction to aftercare ointment or the processes used in the tattoo; and I voluntarily assume and accept all risks that such reactions are possible.I understand that infection is possible as a result of a tattoo, particularly in the event that I fail to take proper care of my tattoo.I will receive written instructions advising me of the proper care of my tattoo and I recognize the necessity for following these instructions.I understand that a tattoo is a permanent change to my body and appearance and no representation has been made that once made, any tattoo can be altered or removedMy tattoo is by my choice alone, and I have not been influenced in anyway by BrowTourage to obtain a tattoo. I consent to the application of my tattoo, and procedures necessary to perform the tattoo.I consent to the application of my tattoo, and procedures necessary to perform the tattoo.I release, forever discharge, and hold harmless BrowTourage and its apprentices, associates, agents, offers and owners, from and against any and all claims, damages, and/or legal procedures actions arising from or in anyway connected to my tattoo and/or by which my tattoo is applied.I understand that there are risks involved in the application of a tattoo and there are NO REFUNDS once a tattoo has been paid.I swear and declare that I am not intoxicated or under the influence of drugs or alcohol.I understand that BrowTourage may refuse to perform my tattoo at BrowTourage's sole discretion.I do not have any medical problems which in any way affect or might affect my tattoo. If I do, I have entered them in the box above.
By signing below, I acknowledge, understand and agree that:
- the staff at BrowTourage do not practice medicine, does not accept health insurance, and have made no representation to the contrary;
- the information provided on this form is accurate and complete to the best of my knowledge, and that BrowTourage is not responsible for complications or problems arising from any incorrect or omitted information;
- some individuals will have complications related to Tattooing application. These complications are usually mild and last only a few days. However, extreme complications are always a possibility. I accept these risks and agree to hold BrowTourage and its employees and contractors harmless for same;
- the staff at BrowTourage will use the information provided above to assess my suitability for the tattooing services.
Date*

MonthDayYear
Date
Client signature (or guardian if under 18 years of age)*

Clear
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