Consent to Tattoo Procedure
Client Information
Full Name
First Name
Last Name
Age
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
By clicking the box below, I agree:
I am 18 years old
*
Yes
No
I have eaten in the last two hours.
Yes
No
Are you under the influence of drugs or alcohol?
Yes
No
I do not haven any known allergies or adverse reactions to latex, iodine, pigments, dyes, disinfectants, soaps, metals, or other such product.
Yes
No
I am not pregnant or breast-feeding.
Yes
No
I understand that reaction to the pigments is still possible, even after the tattoo has healed
Yes
No
I understand that there may be side effects from this procedure, including swelling, bruising.
Yes
No
I do not have any conditions that compromise my immune system.
Yes
No
I have never suffered from any communicable diseases that could be transferred to another person during the procedure.
Yes
No
I do not suffer from hemophilia, epilepsy, narcolepsy, dizziness, fainting, or any form of seizure causing condition that could interfere with the procedure
Agreed
Not Agreed
I understand that every care has been taken to ensure that this procedure has been carried out in a hygienic manger, and the aftercare of the tattoo is my sole responsibility
Agree
Not Agree
I give my consent to allow Raven Studio, LLC the use of photography which may include myself & or parts of my body for marketing and social media purposes
Yes
No
Skin conditions (e.g. Rashes, eczema, infection, psoriasis, freckles, etc.)
If yes, please identify the condition.
Acknowledgment and Waiver
I acknowledge that both written and verbal instructions regarding risk, outcome, and aftercare were given to me
I understand that if I have any skin treatments, laser hair removal, plastic surgery or other skin altering procedures, it may result in adverse changes to my tattoo.
I acknowledge that the Tattoo Shop does not offer refund.
I consent to any actions or conduct of the representatives and employees of the tattoo shop, necessary to perform the procedure.
I understand that I need to take care of the tattoo by following the instructions given to me.
I understand that I might get an infection if I don't follow the instructions given to me in regards of taking care of my tattoo.
I agree that touch up work needed due to my own negligence will be at my own expense.
I confirm that the information I provided in this document is accurate and true.
Signed Date
-
Month
-
Day
Year
Date
Client Signature
Deposit for Tattoo Appointment
*
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USD
Deposit for Tattoo Appointment 3.5% Will be added
Credit Card
Please Take A Picture of Your I.D.
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