Consent Form

Consent Form

Please fill out this form before your tattoo appointment with @izlucytattoo.
Client Information
Name*

First NameLast Name
Age
Birth Date

MonthDayYear
Date
Phone Number*
Format: (000) 000-0000.
Email
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Pre-Procedure Questionnaire
Are you under the influence of drugs or alcohol?*

YesNo
FEMALE ONLY: Are you pregnant or nursing?*

YesNo
Do you have any skin conditions?*

YesNo
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 Tattoo Shop portfolio showcased.
*

I acknowledge that the Tattoo Shop does not offer refund.
*

I agree that the studio does not have a way of identifying if I am allergic to the elements or ingredients that will be used for my tattoo.
*

I understand that I need to take care of the tattoo by following the instructions given to me by the Tattoo Shop.
*

I understand that I might get an infection if I don't follow the instructions given to me in regards to the proper care of my tattoo.
*

I indemnify and hold harmless the Tattoo Shop against any claims, expenses, damages, and liabilities.
*

I confirm that the information I provided in this document is accurate and true.
Signed Date

MonthDayYear
Date
Client Signature
Should be Empty:

Consent Form

Client Information

Pre-Procedure Questionnaire

Acknowledgment and Waiver