Consent Form - Kustom Creations

1
Full Legal NamePreferred name can be entered on the next page
First Name
Last Name
2
Preferred Name (if different from legally documented name)Leave blank if same as legal name
First Name
Last Name
3
Today’s Date Today's Date
Date
Day
Month
Year
4
Preferred PronounsOptional
She/Her
He/Him
They/Them
Prefer Not To Say / Other
5
D O B You must be over 18 to get a tattoo by law
Date
Day
Month
Year
6
Which artist is doing your tattoo?
Tin
Lauren
Rylan
Guest Artist
Lek
Wendy
7
Body Placement Of TattooIe arm / leg / chest / back / hand
8
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
9
Email
example@example.com
10
Phone Number
Area Code
Phone Number
11
If you answer YES to these questions you can not be tattooed today ARE YOU UNDER THE INFLUENCE OF DRUGS OR ALCOHOL? ARE YOU PREGNANT OR NURSING?
YESNO
12
Do you have a communicable (infectious) disease? If YES, please detail that disease here. If you do not, write N/A. If YES please also communicate this to your artist.
13
Do you have any skin conditions? If yes, detail below, if not write N/A Rashes / Eczema / Infections / Psoriasis / Freckles / etc. If YES please also communicate this to your artist.
14
Please detail any relevant medical history we should be aware of. If there is nothing to note, write N/A Cardiovascular disease / Epilepsy / Etc. Anything worthy of note please also communicate to your artist.
15
Please show your artist the consent form before continuingartist sign to say that all areas have been filled in to a satisfactory level
16
Please read and type your name below to confirm you understand the followingAcknowledgement and waver. By signing below you state that (1) you understand that this is a permanent procedure that will alter your body (2) you understand that photographs or videos may be taken of your tattoo and used for social media / promotional purposes (3) you understand that the studio does not offer refunds (4) you understand that the studio does not have any way to identify any allergies to ingredients or elements used in and during the tattoo, and that allergies may have developed since previous tattoos (5) you take full responsibility for after-care, as instructed by the artist (6) you understand that infection is a risk if you do not follow all after care instructions (7) you indemnify and hold harmless Kustom Creations Tattoo Studio and the Artists against any claims, expenses, damages, and liabilities (8) you confirm that all information is accurate and true at the time of writing it (9) you understand that the studio and the artist reserve the right to refuse service for any reason, at any point (10) you understand that all information given is for private use only, never given to any third parties, but may from time to time be used to communicate with you regarding promotional and studio-specific information
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