Consent and Waiver for PMU and Tattoo Services by Ariel
Please Fill out Your Information
Name
First Name
Last Name
Drivers License or Personal ID Number
Birth Date
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Month
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Day
Year
Date
Phone Number
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Pre-Procedure Questionnaire
Have You Consumed Alcohol in the Last 24 Hours?
Yes
No
FEMALE ONLY: Are you pregnant or nursing?
Yes
No
Do you have a communicable disease?
Yes
No
Do you have any skin conditions?
Yes
No
Please list type if so; e.g. Rashes, eczema, infection, psoriasis, keloids…. Name any medication you are currently using to treat it with.
If yes, please identify the condition.
Please give a brief description of your medical history, including any medications (e.g. DIabetes, Cardiovascular Disease, Epilepsy, Autoimmune Disorders, Blood-related disease, Allergies)
Acknowledgment and Waiver
I understand that this procedure is a permanent change to my skin and body.
I acknowledge that the Studio does not offer refunds, and any follow up visits are an additional charge.
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 procedure.
I understand that I need to take care of the area by following the aftercare instructions given to me by the Artist
I understand that I risk getting an infection or compromising the results, if I don't follow the aftercare instructions given to me by the Artist.
I realize there are risks associated with this procedure, and release the Studio of any claims, expenses, damages, and liabilities
I confirm that I am at least 18 years of age
I confirm that the information I provided in this document is accurate and true.
Signed Date
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Month
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Day
Year
Date
Client Signature
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