Fine Line Tattoo Consent Form

Client Information

Please fill out the information below to the best of your knowledge
Full Name *

First NameLast Name
Age*
Date of Birth*

MonthDayYear
Date
Phone Number*

Area CodePhone Number
Email*
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Tattoo Description*
Please describe your tattoo in detail. Size, placement, color, ect.
Health Questionnaire

Please select all that apply to you
Do you have any allergies such as:*

AntibioticsMetalsSoapsLatexAlcoholCosmeticsAdhesivesPetroleumLanolin OilLidocaineShellfishNoneOther
Diseases:*

HepatitisTuberculosisGonorrheaSyphilisHIV/AIDSHerpesStaphAuto-Immune DisorderAsthmaCOVID-19InfectionsNoneOther
Overall Health*

Heart DiseaseHigh Blood PressureDiabetesCurrently Pregnant or BreastfeedingProne to FaintnessSkin Disease/RashEpilepsyHemophiliaProne to Scarring/KeloidsPsoriasisBlood ThinnersEczemaNoneOther
Emergency Name and Phone Number
(Optional)
Are you currently on any medication? Please list:
(Optional, but encouraged)
Do you have other Tattoos?
If so how many?
Acknowledgment and Waiver

By completing and signing this form, I acknowledge that I have been given the full opportunity to ask any and all questions which I might have about obtaining a tattoo from Ink & Glow, and that all of my questions have been answered to my full and total satisfaction. I specifically acknowledge that I have been advised of the facts and matters set forth, and I agree as follows:
I have truthfully represented to Ink & Glow that I am over the age of eighteen (18).*

I agree
I acknowledge that it is not reasonably possible for Ink & Glow to determine whether I might have an allergic reaction to the dyes, pigments or processes used in my tattoo, and I agree to accept the risk that such a reaction is possible.*

I agree
I acknowledge that I have advised my tattoo artist of any condition that might affect the healing of this tattoo. I do not have medical or skin conditions such as but not limited to: acne, scarring (keloid), aczema, psoriasis, freckles, moles, or sunburn in the area to be tattooed that may interfere with said tattoo. If I have any type of infection or rash anywhere on my body, I will advise my tattooer.*

I agree
I am not pregnant or nursing.*

I agree
I am not under the influence of alcohol or drugs.*

I agree
I acknowledge that infection is always possible as a result of obtaining a tattoo, particularly in the event that I do not take proper care of my tattoo. I have received aftercare instructions and I agree to follow them while my tattoo is healing. I agree that any touch-up work needed, due to my own negligence, will be done at my own expense. This includes sun and ultraviolet frequency damage.*

I agree
I acknowledge that a tattoo is a permanent change to my appearance and that no representations have been made to me as to the ability to later change or remove my tattoo. To my knowledge, I do not have physical, mental or medical impairment or disability which might affect my well being as a direct or indirect result of my decision to have a tattoo.*

I agree
I acknowledge that if my tattoo is a symbol, or something written in a language other than English, that Ink & Glow are not responsible for what it may or may not mean.*

I agree
I acknowledge that if my tattoo includes text, that I am responsible for the correct spelling, grammar and punctuation. I have proofed the text before it is applied as a tattoo.*

I agree
I acknowledge that variations in colour and design may exist between any tattoo as selected by me and as ultimately applied to my body. I understand that if my skin is dark, the colours will not appear as bright as they do on light skin.*

I agree
I acknowledge the decision for obtaining my tattoo is my own free will and choice. I consent to the location of the tattoo and the performance of the tattoo procedure.*

I agree
I acknowledge and agree to following any and all instructions provided to me regarding the maintenance of a sanitary environment while I am being tattooed.*

I agree
I agree that the tattoo design is correctly drawn to my specifications and I agree to allow for artist interpretation of the image.*

I agree
I agree to immediately notify my tattooer if I feel lightheaded, dizzy and/or faint before, during or after the procedure. Failure to do so releases Ink & Glow and my tattooer of all responsibility.*

I agree
I agree that I have not been in contact of Covid-19 and show no signs of being sick.*

I agree
Signed Date*

MonthDayYear
Date
Client Signature*

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Client Information

Health Questionnaire

Acknowledgment and Waiver