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

CityCounty

Postal Code
Health Questionnaire

Please select all that apply to you
Overall Health*

Bleeding problems (nose bleeds, gum bleeds, easy bruising, etc.)Poor or abnormal healing (wide scars, raised scars, larger scars, keloids, slow healing)Skin DisordersLiver problems (Hepatitis)High blood pressureHeart disease (heart attack, arrhythmia, irregular pulses, heart murmur, etc.)Lung disease (asthma, pneumonia, chronic bronchitis)Hormonal diseases (Diabetes, Thyroid problems, etc.)Kidney/Bladder disease (prostate)Stomach disease (ulcers, heartburn, etc.)Neurologic disease (stroke, seizure, fainting)Hay fever, Hives, EczemaGlaucomaDo you have any artificial joints, artificial heart valves, or metal pins/plates or pacemaker?Disorders of the immune systemTattoosBlood transfusionsEmotional problems (depression, anxiety, panic disorder, etc.)Have you been told you need antibiotics PRIOR to energy based treatments?Rare disorders (Hereditary Angioedema, Malignant Hyperthermia)Are you harder to “freeze” or “numb” with local anaesthetics than most people?None of the adoveOther
I am not pregnant or nursing.*

I agree
Weekly Alcohol Intake?*
Weekly Cigarette use? *
Other drug use?*
Are you allergic to or have had a “bad reaction” to any of the following local anaesthetics occasionally used in surgery?*

NovocaineXylocaineSkin TapeIodineValiumPenicillinCodeinePrednisoneSubstances applied to skinNone of the adove
Emergency Name and Phone Number
(Optional)
List all prescription or non-prescription medications, drugs, vitamins, or nutritional supplements you take either regularly or occasionally: (Including Vitamin E, over-the- counter pain and arthritis medications like Advil or Motrin, etc*
Please list any operations, or serious medical illness not mentioned above or give details of questions answered yes above.
GP Information and Address*
Signed Date*

MonthDayYear
Date
Client Signature*

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Client Information

Health Questionnaire