Tattoo / Piercing Form
Client Information
Name
First Name
Last Name
Age
Birth Date
-
Month
-
Day
Year
Date
Phone Number
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Pre-Procedure Questionnaire
Are you under the influence of drugs or alcohol?
Yes
No
FEMALE ONLY: Are you pregnant or nursing?
Yes
No
Do you have a communicable disease?
Yes
No
Do you have any skin conditions?
Yes
No
Skin conditions (e.g. Rashes, eczema, infection, psoriasis, freckles, etc.)
If yes, please identify the condition.
Please tell about your medical history (e.g. DIabetes, Cardiovascular Disease, Epilepsy, Blood-related disease etc.)
If yes, please identify the condition.
Acknowledgment and Waiver
I understand that this procedure is a permanent change to my skin and body.
I allow my tattoo / piercing to be photographed and be used for Tattoo Shop portfolio showcased.
I acknowledge that the Tattoo Shop does not offer refund.
I agree that the studio does not have a way of identifying if I am allergic to the elements or ingredients that will be used for my tattoo/ piercing
I understand that I need to take care of the tattoo by following the instructions given to me by the Tattoo/ piercing Shop.
I understand that I might get an infection if I don't follow the instructions given to me in regards of taking food care of my tattoo/ piercing.
I indemnify and hold harmless the Tattoo/ piercing Shop against any claims, expenses, damages, and liabilities.
I hereby authorize celestial ink use of photographs, i consent to those materials becoming the sole property of celestial ink and i will no longer be entitled to them, provided that it is done for lawful purposes
I confirm that the information I provided in this document is accurate and true.
Signed Date
-
Month
-
Day
Year
Date
Client Signature
Submit
Submit
Should be Empty: