Tattoo Procedure Waiver

T A T T O O - I N T A K E F O R M / W A I V E R
Date

MonthDayYear
Date
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Date of Birth*

MonthDayYear
Date
Are you Under 18 Year Old?*

YESNO
Emergency contact*

First NameLast Name
Emergency contact Phone Number*
Please enter a valid phone number.
PARENTAL CONSENT
Parent/Guardian Name

Parent/Guardian First NameParent/Guardian Last Name
Parent/Guardian Phone Number
Please enter a valid phone number.
Relation to client

ParentGuardianOther
Parent/Guardian Signature

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MEDICAL HISTORY
PLEASE CHECK IF ANY CONDITIONS LISTED BELOW APPLY TO YOU:

DiabetesHemophiliaSkin Sensitivity to soap or disinfectantSkin LesionsSeizuresEpilepsyFaintingBlood PressureOther
Do you have additional allergies to Metal,Soaps,Cosmetics or Alcohol?*

YESNO
Are you currently pregnant?*

YESNO
Are you currently taking medication that thins the blood?*

YESNO
Are you currently under the care of a physician?*

YESNO
Are you currently under influence of drugs and alcohol?*

YESNO
Do you have any communicable disease?*

YESNO
Do you have any medical or skin conditions that might affect the outcome of this procedure?*

YESNO
Please INITIAL in the boxes provided after reading to show you understand each provision. Feel free to ask any question regarding this wiaver.
I,First Name* Last Name* acknowledge that by signing this waiver that I have been given full opportunity to ask any and

all questions which I might have about obtaining a piercing from INK ME TORONTO All of my questions have been answered to my fullest and total

satisfaction. I specifically acknowledge that I have been advised of the facts and matters below and I agree as follows
**PLEASE ASK YOUR ARTIST ABOUT THE PRICE OF YOUR TATTOO BEFORE BEGINNING OF THE PROCEDURE - it is your

responsibility to confirm the price of the tattoo, and we assume no responsibility for misunderstanding in this regard.
Signature*

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FOR OFFICE USE ONLY! DO NOT FILL
TATTOO ARTIST

SAMITTANISH
TATTOO LOCATION
PAID IN FULL

YESNO
TATTOO DISCRIPTION
DATE PROCEDURE COMPLETED

MonthDayYear
Date
NOTES
Should be Empty:

T A T T O O - I N T A K E F O R M / W A I V E R

PARENTAL CONSENT

MEDICAL HISTORY

Please INITIAL in the boxes provided after reading to show you understand each provision. Feel free to ask any question regarding this wiaver.

FOR OFFICE USE ONLY! DO NOT FILL