Tonna Sky Beauty Customer's Medical History & Consent Form

CUSTOMER'S INFORMATION & MEDICAL HISTORY

For Tattoo
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*
MM/DD/YYYY
Phone*
Format: (000) 000-0000.
Email*
example@example.com
Emergency Contact*

First NameLast Name
Phone*
Format: (000) 000-0000.
Is this your first tattoo?*
List any medications you have been taking in the past 6 months:*
Have you received chemotherapy or radiation in the past year?*

YesNo
Have you ever had an allergic reaction to any of the following:*

LatexLanolinVaseline foodsLidocaine paintsHair dyesMedicationMetalsCrayons GlycerinNone of the above
Have you ever had a cold sore? If yes, please contact your physician for a preventative prescription capsule to prevent a cold sore.*

YesNo
Are you currently taking medication that thins the blood?*

YesNo
Are you currently under the care of a physician? If yes, please explain.*

NoYes, please explain.
Do you take antibiotics when going to the dentist/before surgical procedures? If yes, why?*

NoYes
Are you pregnant or nursing?*

YesNo
Have you ever had one of the following?*

Hair lossTrichotillomaniaHemophilia/Bleeding disorderLiver diseaseThyroid Disturbances AnemiaHIVAlopeciaCancerSensitivity to cosmeticsArtificial heart valve fainting spells or dizinessTumors, growths, cystsHealing problemsProlonged bleedingLow blood pressureCirculatory problems/Cardiac Valve DiseaseBotox/Filler injectionsDiabetesHigh blood pressureHepatitisEpilepsyHypertrophicKeloid scarsNone of the aboveOther
Do you bruise/bleed easily?*

YesNo
The above information is complete and accurate to my fully understanding of my medical history.*
Today's date*

MonthDayYear
Date
Print Name*

First NameLast Name
Proof of Identification

Please upload the front of your identification.
Type of Document
Document's Number:
Identification Proof Picture*

Cancelof
Photos and Videos Release
I have been informed that Tonna Sky Beauty may record videos and take pictures of me during my appointment for social media and marketing purposes.

I understand that the videos and pictures may be used on various marketing platforms, including but not limited to social media websites, promotional materials, and advertisements.

I acknowledge that my participation in the recording of videos and taking of pictures is voluntary and that I will not receive any financial compensation for the use of these materials.
I have the following choices:*

I agree to the recording of videos and taking of pictures as described above.I deny consent for the recording of videos and taking of pictures as described above.
TONNA SKY BEAUTY CONSENT FORM
I acknowledge by signing this release that I have been given the full opportunity to ask any and all questions which I might have about obtaining body art tattoo from Tonna Sky Beauty (hereafter called "Technician") and that all of my questions have been answered to my full and total satisfaction. Specifically acknowledge that I have been advised of the matters set forth below and agree as follows (If any of these are not checked, please confirm with your artist as you might not be able to proceed with the tattoo):

1. I acknowledge that obtaining body art tattoo is my choice alone and the application of body art tattoo will result in a permanent change to my appearance, and that needles and inks will go into my skin. No representation has been made to me as to the ability to later restore the skin involved in body art tattoo to the original condition, and it is very costly to remove.2. I am 18 years and older.3. I am not pregnant or nursing. I do not have any history of herpes infection at the proposed procedure site. I do not have epilepsy, diabetes, allergic reaction to latex or antibiotics, hemophilia or other bleeding disorder. I do not have cardiac value disease or suffer from any heart condition or take medications that thins my blood.4. If I suffer from hepatitis, or other risk factors for bloodborne pathogen exposure, or any other communicable disease, I have informed the Technician of the fact and have been advised of any medications and procedure necessary to promote the satisfactory healing of my tattoo.5. I have advised Technician to any allergies to latex gloves, soaps, or medications. I understand it is not the Technician's responsibility to determine if I have any allergic reaction.6. I do not suffer from any medical or skin condition(s) such as, but not limited to: keloid or hypertrophic scarring, psoriasis at the site of the tattoo, or any open wounds or lesions at the site of the tattoo.7. I do not have a history of medication uses or currently using mediation, including being prescribed antibiotic prior to dental or surgical procedures.8. I have truthfully represented to the technician that I am 18 years of age or older.9. I am not the recipient of an organ or bone marrow transplant or, if I am, I have taken the prescribed preventative regimen of antibiotics that is required by my doctor in advance of an invasive procedure as tattooing or piercing.10. I am not under the influence of any drugs or alcohol. To my knowledge, I do not have any physical, mental, or medical impairment or disability that might affect my well-being as a direct or indirect result of my decision to have a tattoo at this time.11. I acknowledge infection is always possible as a result of body art tattoo, and I agree to follow all suggested instruction concerning the care of the body art tattoo while healing.12. I understand there is a possibility of an allergic reaction and infection and will not hold Tonna Sky Beauty (hereafter called "Technician" or "Artist") accountable for any allergic reactions to the elements/inks used during our session.14. I understand I will have body art tattoo applied using appropriate instruments and sterilization techniques. I understand that the body art tattoo usually takes 2 weeks or longer to heal. I agree to release and forever discharged and hold harmless, the technician, all employees, contractors and the management of Tonna Sky Beauty from any and all claims of negligence, damages, or legal actions arising from connected in any way with my tattoo, the procedure, and conduct used in my tattoo and assume all responsibility for the decision(s) made consenting to this permanent procedure.15. I am aware that tattoo inks, dyes, and pigments have not been approved the federal Food and Drug Administration and that the health consequences of using these products are unknown.16. Tonna Sky Beauty is not responsible for the meaning or spelling of the symbol or text that I have provide to them or chosen from the flash (design) sheets.17. Variations in color and design may exist between the tattoo art I have selected and the actual tattoo when it is applied to my body. I also understand that over time, the colors and the clarity of my tattoo will fade due to unprotected exposure to the sun and the naturally occurring dispersion of pigment under the skin.18. 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 restoration of my skin to its exact appearance before being tattooed.19. I WAIVE AND RELEASE to the fullest extent permitted by law any person of Tonna Sky Beauty from all liability whatsoever, including but not limited to, any and all claims or causes of action that I, my estate, heirs, executors or assigns may have for personal injury or otherwise, including any direct and/or consequential damages, which result or arise from the procedure and application of my tattoo, whether caused by the negligence or fault of either the Tonna Sky Beauty, or otherwise.20. I acknowledge that Tonna Sky Beauty has a NO REFUND policy on tattoos and/or retail sales and will not for one.21. I agree to reimburse Tonna Sky Beauty for any attorneys' fees and costs incurred in any legal action I bring against Tonna Sky Beauty and in which either the Artist of Tonna Sky Beauty is the prevailing party. I agree that the courts of located in the County of Orange within the State of California shall have jurisdiction and venue over me and shall have exclusive jurisdiction for the purposes of litigating any dispute arising out of or related to this agreement.22. I have been fully informed of the risks of body art including but not limited to infection, scarring, difficulties in detecting melanoma, and allergic reactions to tattoo pigment, jewelry metals, latex gloves, and antibiotics. Having been informed of the potential risks associated with body art, I still wish to proceed with this body art procedure and assume any and all risks that may arise from this body art procedure. I acknowledge that I have been given adequate opportunity to read and understand this document, that it was not presented to me at the last minute and grasp that I am signing a legal contract waiving certain rights to recover damages against Tonna Sky Beauty.
Signature*
Print Name*

First NameLast Name
Date*

MonthDayYear
Date
Should be Empty:

CUSTOMER'S INFORMATION & MEDICAL HISTORY

Proof of Identification

Photos and Videos Release

TONNA SKY BEAUTY CONSENT FORM