Tattoo Consent Form
Katie Haus, Firefly Tattoo, 502 W 4th Street, Suite 8, Bloomington, IN 47404
Name
First Name
Last Name
Pronouns
e.g. they/them, she/her, etc.
Age
e.g. 34
Birthdate
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Description of tattoo
Location of tattoo
Have you eaten in the last eight hours?
Yes
No
Have you had any alcohol in the last eight hours?
Yes
No
Are you prone to fainting?
Yes
No
Are you prone to heavy bleeding?
Yes
No
Have you taken aspirin, ibuprofen, or an anti-coagulant in the last 24 hours?
Yes
No
Are you diabetic?
Yes
No
Do you have any heart conditions?
Yes
No
Are you pregnant or nursing?
Yes
No
Are you pregnant or nursing?
Yes
No
Do you have any communicable diseases?
Yes
No
Do you have any skin conditions (e.g. rashes, eczema, keloids, infection, psoriasis, freckles, etc.)
Are you allergic to anything? If so, what?
Are there additional things I should know about you that could improve your tattoo experience (e.g. noise level adjustments, trauma triggers, low energy, prefer not to talk, etc.)?
I understand that a tattoo is a permanent change to my body and I acknowledge the decision for obtaining my tattoo is by my own free will and choice. I consent to the location of the tattoo and the tattoo procedure.
I acknowledge that it is not feasibly possible for my artist to determine whether I might have an allergic reaction to the dyes, pigments, or processes used in my tattoo, and I agree to accept the risk that such a reaction may occur.
I acknowledge and agree to follow any and all instructions provided to me regarding the maintenance of a sanitary environment while I am being tattooed.
I understand that I need to take proper care of the tattoo by following the instructions given to me by Katie Haus and Firefly Tattoo.
I allow my tattoo to be photographed for promotional and portfolio purposes.
I understand that Katie Haus and Firefly Tattoo do not offer any refunds.
I indemnify and hold harmless Katie Haus and Firefly Tattoo LLC against any claims, expenses, damages, and liabilities.
I indemnify and hold harmless Katie Haus and Firefly Tattoo LLC against any claims, expenses, damages, and liabilities.
Please upload a photo of your drivers license.
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Today's Date
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Month
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Client Signature
May I contact you approximately 6 months after your appointment to request healed photos of your tattoo?
Yes
No
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