Tattoo & Piercing Consent Form

Wicked Heart Art Collective

CONSENT TO APPLICATION OF TATTOO/PIERCING AND WAIVER OF ALL CLAIMS
303-997-7651

9116 WEST BOWLES AVENUE LITTLETON, CO 80123
Client Name (Including clients under 18. Parents: Your information is needed in the next section)*

First NameLast Name
Todays Date*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Date
Drivers License/State ID Number/Birth Certificate/Passport*
Issuing State on ID*
Take Photo of ID (NOT a selfie)*
Emergency Contact*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.
- Minors Legal Guardian
  
  Must be completed for any client under the age of 18. If you are a parent or guardian, your information goes here.
- Name
  
  First NameLast Name
- Phone Number
  Please enter a valid phone number.
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Date of Birth
  
  MonthDayYear
  Date
- Drivers License/State ID Number
- Take Photo of Drivers License - NOT A SELFIE
- Parent or Legal Guardian Liability Agreement:
  
  I affirm that I am the legal parent or guardian of the minor listed above and I consent to the tattoo/piercing procedure. I have provided valid government-issued identification for both myself and the minor, as required by law.
- Signature*
  
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Wicked Heart Art Collective