Tattoo Consent Form

Tattoo Consent Form

Bones & Clove
Client Information
Name

First NameLast Name
Date of birth

MonthDayYear
Date
Pre-Procedure Questionnaire
Are you under the influence of drugs or alcohol?
Have you eaten in the last 2 hours?
FEMALE ONLY: Are you pregnant or nursing?
Do you have a communicable disease?
Do you have any skin conditions?
Skin conditions (e.g. Rashes, eczema, infection, psoriasis, freckles, etc.)
If yes, please identify the condition.
Skin allergies including to but not limited to ink dyes or pigments.
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.
Do you have any other medical conditions you feel we should know about? Lupus? Diabetes? Hemoplilia?
If yes, please identify the condition.
Allergies to latex?
Acknowledgment and Waiver
Other
Other
NOTE: Please contact your physician at the first sight of infection or swelling.
Client Signature
Signed Date

MonthDayYear
Date
File Upload

Cancelof
If you have health or medical concerns please consult a physician before engaging in body art procedure.
Should be Empty: