Fifth Estate Tattoo Consent Form

Consent to Tattoo Procedure Medical History Release Form
Client Information
Name*

First NameLast Name
Birth Date*

MonthDayYear
Date
Phone Number*
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Pre-Procedure Questionnaire
Artist name (if known)
Description of tattoo design*
Area of body to be tattooed (if known)
Please check any condition below that applies to you

PregnantEpilepsyHeart conditionAsthmaDiabetesScarring / KeloidingProne to faintingHerpesHepatitisHemophiliaEczema / PsoriasisBreast FeedingHIV / AIDSBlood ThinnersInfectionsT.B.
Do you have any allergies?*

YesNo
Please list your allergies
Are you taking any medications?*

YesNo
Please list any medications you are currently taking
Are there any known medical conditions or contagious diseases that may affect your tattoo procedure?*

YesNo
Please list any medical conditions or contagious diseases that may affect your tattoo procedure
Acknowledgment and Waiver
I agree to the following:*

I hereby certify that to the best of my knowledge this information is correct.All questions regarding the tattoo procedure have been answered to my satisfaction.I agree that said tattoo is correctly drawn to my specifications.I understand that said tattoo is permanent.This is to certify that I am at least 18 YEARS OF AGE.I am NOT under the influence of alcohol or drugs.I understand there is a possibility of allergic reaction.I understand there is a possibility of infection.I agree to allow for artist interpretation.I agree to follow all instructions concerning the aftercare of my tattoo.I hereby release FIFTH ESTATE TATTOO and ARTISTS of all responsibility for said tattoo.I understand that there are no refunds for any ser vices provided by FIFTH ESTATE TATTOO.
Signed Date*

MonthDayYear
Date
Client Signature*

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Please attach a photo of the front of your Driver License or Identification (ID) Card*

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Consent to Tattoo Procedure Medical History Release Form

Client Information

Pre-Procedure Questionnaire

Acknowledgment and Waiver