Tattoo Consent Form
Please fill out form COMPLETELY prior to appointment.
Full Name
First Name
Last Name
Age
Format: (ex:23).
Birthdate
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Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Pre-Procedure Questionnaire
Are you under the influence of drugs or alcohol?
Yes
No
Do you have a communicable disease?
Yes
No
Do you have any skin conditions?
Yes
No
If yes, please identify the condition(s).
(e.g. rashes, eczema, infection, etc.)
Please tell me about your medical history.
(e.g. diabetes, epilepsy, blood-related disease, allergies, etc.)
For your comfort :) - Are you a talker? Or do you prefer a quiet environment?
Talker
Quiet
Acknowledgement and Waiver
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I understand that this procedure is a permanent changed, my skin and body.
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I allow my tattoo to be photographed and be used for my artist’s portfolio.
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I acknowledge that the tattoo shop does not offer refund.
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I understand that I need to take care of the tattoo by following the instructions given to me by the artist.
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I understand that I might get an infection if I don’t follow the instructions given to me in regards of taking good care of my tattoo.
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I indemnify and hold harmless the tattoo shop against any claims expenses, damages, and liabilities.
Valid Drivers License
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of
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I confirm the information I provided in this document is accurate and true.
Signed Date
-
Month
-
Day
Year
Date
Sign Full Name
Submit
Should be Empty: