Medical Consent Form

Medical Consent Form ~

Please fill out this consent form with all current up-to-date details on the day of your appointment before arriving to the studio.

If you have any of the medical issues highlighted on this form this could mean you are unable to be tattooed. If you have any questions or your medical issue isn't listed on this form please contact me via email.

tvdinnertattoo@gmail.com
*DATA PROTECTION: THE INFORMATION YOU PROVIDE ME WITH WILL NOT BE SHARED WITH ANY THIRD PARTIES, IT WILL BE STORED IN A SECURE PLACE AND WILL BE DESTROYED IN COMPLIANCE WITH DATA PROTECTION LAWS.*
Full Name ~*

First NameLast Name
Date of Birth ~*

MonthDayYear
Today's Date ~*

MonthDayYear
Please tick the box to confirm you have read and understand all of the pre-tattoo information provided and are suitably prepared for your tattoo ~*

I have read and understand all of the pre-tattoo information.
Which form of ID are you bringing to your appointment?*
Please tick if you currently have any of the following conditions:

Medical History ~*

	Yes	No
High blood pressure
Low blood pressure
Epilepsy
Cancer
Heart disease
Heart murmurs
History of haemorrhaging
Pace maker
Diabetes
Psoriasis
Impetigo
Warts
Eczema
Acne or using acne medication in the past 6 months
Metal allergy
Latex allergy
Adhesive bandage/plaster allergy
Broken bone/bones
Long COVID

Are you currently taking any medications?*

YesNo
If yes, please detail the medications you are currently taking below ~
Do you suffer from any other health issues including mental health?

YesNoPrefer not to say
If yes please feel free, but not pressured, to write down anything you might need from me to make you feel more safe, comfortable and supported during our appointment ~
Are you neurodivergent?

YesNoPrefer not to say
If yes, feel free to detail below any extra support I can provide to make your tattoo experience better (e.g. noise cancelling headphones, fidget toys, screens) ~
Are you under the influence of drugs and/or alcohol?*

YesNo
Are you leaving the country within the next two weeks?

YesNo
Are you pregnant or breastfeeding?*

YesNo
Are you regularly swimming or spending extended periods of time outdoors?

YesNo
Are you vegan?

YesNo
If your tattoo includes WRITING/NAMES/DATES please provide the correct spellings and/or numbers below for reference to avoid mistakes ~
*DISCLAIMER*

No tattoo can be 100% perfect and this applies to myself especially as I am currently still an apprentice who is constantly learning and improving my technique. Nevertheless, I will always try my best to meet your expectations and provide the best tattoo possible. All skin is different and no one's skin is exactly the same which can be reflected in the healing process. I offer free touch-ups for up to six months after our initial appointment with there being a fee after this period has ended. It is important to note we have CCTV in the studio, please ask me about this if this is an issue.
I HEREBY DECLARE THAT I AM OF LEGAL AGE AND I AM COMPETENT TO SIGN TO SAY I WILL FOLLOW THESE PRE-TATTOO INSTRUCTIONS. IF NOT, MY PARENT OR LEGAL GUARDIAN SHOULD SIGN ON MY BEHALF, AND THAT MY PARENT OR GUARDIAN IS IN COMPLETE UNDERSTANDING AND CONCURRANCE WITH THIS AGREEMENT. I ALSO UNDERSTAND THAT EACH TATTOOER/PIERCER THAT OPERATES FROM THE COCK A SNOOK PREMISES REPRESENTS THEMSELVES ONLY AS AN INDIVIDUAL SOLE TRADER AND IS SELF-EMPLOYED.*

I AGREE
Full Legal Name ~*

First NameLast Name
Preferred Name ~
Preferred Pronouns ~
(e.g. she/her, he/him, they/them)
Date of Birth ~*

MonthDayYear
Address ~*

Street Address Line 1

Street Address Line 2

CityCounty

Postcode
Phone Number*

Area CodePhone Number
Email Address ~*
Emergency Contact ~

Please input the details of your chosen emergency contact so that we can contact them if needed during our appointment.
Full Name ~*

First NameLast Name
Relationship to You ~*
Phone Number ~*

Area CodePhone Number
Today's Date ~*

MonthDayYear
Date
Signature ~*

Clear
Should be Empty:

Emergency Contact ~