Consent Form
Jumpthegun_tatoos
Name
*
First Name
Last Name
Date of Birth
*
-
Day
-
Month
Year
Age
*
Do you have any heart conditions?
*
Yes
No
If yes please explain how this may affect the procedure, and precautions taken or how I may accommodate.
Do you have epilepsy?
*
Yes
No
If yes please explain how this may affect the procedure, and precautions taken or how I may accommodate.
Do you suffer from haemophilia or any other blood clotting disorders?
*
Yes
No
If yes please explain how this may affect the procedure, and precautions taken or how I may accommodate.
Do you suffer from any blood bourne viruses?
*
Yes
No
Do you have diabetes or lupus?
*
Yes
No
If yes please explain how this may affect the procedure, and precautions taken or how I may accommodate.
Have you had any problems from skinhealing in the past? (Ezcema, psoriasis, etc)
*
Yes
No
If yes please explain how this may affect the procedure, and precautions taken or how I may accommodate.
Are you prone to keloid scars?
*
Yes
No
Do you have any allergies?
*
Yes
No
If yes please explain how this may affect the procedure, and precautions taken or how I may accommodate.
Are you on any blood thining medication?
*
Yes
No
Are you pregnant?
*
Yes
No
Are you prone to fainting?
*
Yes
No
If yes please explain how this may affect the procedure, and precautions taken or how I may accommodate.
Any previous reactions to dyes or pigments?
*
Yes
No
If yes please explain how this may affect the procedure, and precautions taken or how I may accommodate.
I declare that I give my full consent to the tattoo being performed by Eileen. I confirm that potential complications (infection, swelling) for the procedure undertaken and aftercare instructions have been explained to me. I confirm that the above information provided by me is correct to the best of my knowledge, that I am over the age of consent for this procedure, and that I am not currently under the influence of alcohol or drugs.
*
Confirm
Signature
*
Today’s Date
*
-
Day
-
Month
Year
Submit
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