Tattoo Informed Consent Form
Client Information
Phone Number
*
Name
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Birth Date
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Pre-Procedure Questionnaire
Are you under the influence of drugs or alcohol?
*
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
Skin conditions (e.g. Rashes, eczema, infection, psoriasis, freckles, etc.)
If yes, please identify the condition.
Please tell about your medical history (e.g. DIabetes, Cardiovascular Disease, Epilepsy, Blood-related disease etc.)
If yes, please identify the condition.
Acknowledgment and Waiver
*
I understand that this procedure is a permanent change to my skin and body.
*
I allow my tattoo to be photographed and be used for Girly Tattoos portfolio showcased.
*
I acknowledge that the Girly-Tattoos, LLC does not offer refunds on any services, artwork, booking fees or consultations.
Other
I WAIVE AND RELEASE to the fullest extent to the law any person of Girly-Tattoos, LLC, from all liability whatsoever, including but not limited to any and all claims of causes of action that I, my estate, heirs, or executors or assigns may have for personal injury or otherwise, including any direct and/or consequential damages, which result or arise from there procedure and application of my tattoo, whether caused by the negligence or fault of myself, Girly-Tattoos, LLC or otherwise.
*
Initals
I understand that I may NOT apply topical anesthetics before any appointments prior to discussion with Girly-Tattoos, LLC. and/or any of their agents, employees, subcontractors, apprentices, or successor's. This may alter the tattoo and the tattoo process significantly. If I do so without informing my artist, I understand that is at my own risk and waive and release Girly-Tattoos, LLC., or otherwise.
*
Inital
Girly-Tattoos, LLC,. has given me the full opportunity to educate myself and ask any question about the procedure and application of my tattoo and all of my questions have been answered to my total satisfaction.
*
Initals
Girly-tattoos, LLC,. has given me full instructions on the care of my tattoo while it is healing. I understand and will follow them. I acknowledge that is is possible that the tattoo can become infected, particularly if I do not follow the instructions given to me. If any touch-up work is needed due to my own negligence, I agree the the work will be done at my own expense. I also agree to immediately notify the artists should complications occur.
*
Initials
I am not under the influence of drugs or alcohol, and I am voluntarily submitting to be tattooed by Girly-Tattoos, LLC,, without duress or coercion.
*
Initials
I do not suffer from diabetes, epilepsy, hemophilia, heart condition(s), nor do I take blood thinning medication. I do not have any other medical or skin condition that may interfere with the procedure, application or healing of the tattoo. I a 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 any invasive procedure such as tattooing or piercing. I am not pregnant or nursing. I do not have a mental impairment that may affect my judgement in getting the tattoo.
*
Initials or Attach Dr's note.
Girly-Tattoos, LLC,, 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.
*
Initials
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.
*
Initials
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 a restoration of my skin to its exact appearance before being tattooed.
*
Initials
I agree to follow the aftercare instructions provided by my artist.
*
I understand that I might get an infection if I don't follow the instructions given to me in regards of taking food care of my tattoo.
Client information Section
Please screenshot this for future reference or review on my site https://www.girly-tattoos.com/rescheduling-cancellation-policy
Booking fees are credited at the end of your tattoo project for making all your scheduled appointments. Booking fees are lost if you do any of the following: Show up with numbing creams. Show up to your appointment with a sunburn. Cancel a week prior to your appointment. Do not show up to your appointment.
*
I understand
Cancellations: Appointments must be cancelled at least 336 hours in advance or 1 week (7 days) BEFORE your appointment to avoid forfeiting your booking fee. If you cancel within 1 week, 336 hours or 7 days before or less than that of your appointment time, your booking fee will be forfeited.
*
I understand
I will NOT send artwork before your tattoo appointment. This is non-negotiable because artwork theft is a very real threat to my business. I will produce thumbnail sketches or lay out sketches on request, or to gain design approval. Not all tattoos can be approached like this particularly coverup tattoos, rework tattoos, or reinvention tattoos.
*
I understand
Interjection policy: The tattoo artist has final say on all aspects of the tattooing process, including the design, placement, and technique. Visitors or spouses are not allowed to interject or interfere with the tattooing process.
*
I understand
We are not responsible for the negative reactions you may have or develop now and into the future after the application of your tattoo. Due diligence is performed to provide the safest environment possible, however complications can occur.
*
I indemnify and hold harmless the Bless Your Heart Tattoo Shop , or Girly-Tattoos, LLC. against any claims, expenses, damages, and liabilities.
I have willingly answered all these questions honestly and accurately.
*
I confirm that the information I provided in this document is accurate and true.
Signed Date
*
-
Month
-
Day
Year
Date
Client Signature
*
Submit
Should be Empty: