Tattoo procedure form of Consent

  • Tattoo procedure form of Consent

    4722 Virginia Avenue St. Louis, MO
  • Todays Date*
     - -
  • Tattooist*
  • Are you currently or have you ever used medications that contain a controlled substance?*
  • Have you ever been diagnosed by a medical doctor as to having contracted communicable disease(s) such as Human Immunodeficiency Virus (HIV), Hepatitis B Virus (HPV) and/or other blood borne pathogens? If so when?*
  • Have you ever been diagnosed by a medical doctor as having allergies? (Not seasonal allergies. Being allergic to something that would give you a severe adverse reaction)*
  • Have you recently been diagnosed by a medical doctor as to having a disease or condition that could affect the healing process, including diabetes?*
  • Are you currently under the influence of any illegal substances?*
  • Have you been diagnosed with jaundice in the last 12 months?*
  • Are you currently using any medications that contain blood thinners?*
  • Are you currently using any medications that weakens the immune system?*
  • Are you currently pregnant?*

  • I,   *   *   am giving full consent and artistic liberty to the selected tattooist to apply the design discussed in detail which I have approved of/proofread/requested in permanent fashion by means of the procedure of tattooing. I understand that there is pain involved and I have taken the proper steps to be fully nourished, hydrated, and prepared for the aforementioned process. I am 18 years or older in age and have come here to receive a tattoo on my own free will. 

    I will follow all instructed aftercare and understand that if I stray from what is professionally suggested the result could lead to infections and infections could lead to undesired circumstances.

    I acknowledge that I am aware certain medical conditions and treatments and/or medications used to treat those medical conditions may be adversely impacted by the procedure of tattooing. Such medical conditions include but are not limited to, impaired kidney and/or liver function, diabetes, jaundice, medication containing blood thinners and medications that weaken the immune system. 
    I further acknowledge that the tattoo and/or brand should be considered permanent; that said tattoo or brand can only be removed with a surgical procedure or laser removal and that any effective removal may result in permanent scarring and disfigurement. 
    I have read this form and can confirm that all the information I have given is correct. I understand that this is a form of consent and I agree to be legally bound by it. 

  • By signing this I relinguish any (and all) liability regarding the application, healing, final result, appearance, and/or my personal health status away from Sign of the Times Tattoo.  I acknowledge that the artist holds the accountability rather than the shop itself. I am confident that the licensed tattooist in the state of Missouri has had the proper training and any lapse in universal procedure is due to lack of state involvement in safety.

  • Artists only from this point. Only artists can submit form

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