Consent to Tattoo Procedure Medical History Release Form
Client Information
Name
*
First Name
Last Name
Birth Date
*
-
Month
-
Day
Year
Date
Phone Number
*
Format: (000) 000-0000.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / 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
Pregnant
Epilepsy
Heart condition
Asthma
Diabetes
Scarring / Keloiding
Prone to fainting
Herpes
Hepatitis
Hemophilia
Eczema / Psoriasis
Breast Feeding
HIV / AIDS
Blood Thinners
Infections
T.B.
Do you have any allergies?
*
Yes
No
Please list your allergies
Are you taking any medications?
*
Yes
No
Please list any medications you are currently taking
Are there any known medical conditions or contagious diseases that may affect your tattoo procedure?
*
Yes
No
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
*
-
Month
-
Day
Year
Date
Client Signature
*
Please attach a photo of the front of your Driver License or Identification (ID) Card
*
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