Medical History Form
Body tattoos
Full Name
*
First Name
Last Name
What is your age?
*
Contact Number
*
Format: (000) 000-0000.
Email Address
*
example@example.com
Artist
*
How did you hear about us?
Google
Intagram
Referral
Other
Is this your first tattoo?
*
Yes
No
Check the conditions that apply to you or any member of your immediate relatives:
Accutane
Cancer/Chemotherapy
Iron Deficiency/Anemia
Hemophilia
Hypoglycemia
Heart Problems/Epilepsy (need doctors consent)
Pregnant/Breast Feeding
Keloid Scars (need doctors consent)
Diabetes (need doctors consent)
Hepatitis
High Blood Pressure
On Blood Thinners
Cold Sores/Shingles
HIV/AIDS
MRI in the near future?
Auto immune disease
Menopause
Laser
Skin Disorders (eg. psoriasis, eczema, rashes, breakouts)
Organ Transplant (need doctors consent)
Other
File Upload for doctors consent
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If you checked one of the options : Heart Problem/Epilepsy or Diabetes, Hemophiliac(bleeder), HIV/AIDS, please explain?
Do you have any medication allergies?
Yes
No
Not Sure
Allergies
Antibiotic Ointments
Latex
Rubber
Nuts
Essential Oils
Makeup
Medications
Glycerine
Lidocaine
Petroleum
Other
I acknowledge that any information contributed by me is true, to the best of my knowledge, and that the present condition of the area that has been treated or will be treated is stated on this record. Signature
*
Are you currently taking any medication?
Yes
No
If yes, please type all medications taken in the last 6 months.
Upload ID for proof of age(You can show only picture, name and age)
*
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Studio Consent Form
Please READ and INITIAL the statements below to indicate: I understand, am aware, and accept the following completely:
I hereby authorize said artist to perform upon myself a body tattoo. If any unforeseen condition arises in the course of the procedure(s) I further request and authorize her to use her full judgment and do whatever he/ she deems advisable and necessary in the circumstances. That I have read all of the information in the FAQ/AFTERCARE/POLICIES sections of the artist's Instagram and followed all of the pre-procedure instructions prior to the appointment.
*
That although allergic reactions and pigment migration are rare, they may happen to me and I accept all responsibility if these occur. That non-toxic pigments are used during the procedure and are considered permanent. That the highest standards of hygiene are met, and that single-use sterile disposable needles, hand tools, and protection barriers are used and disposed of for each individual client, procedure and visit. That tattoos can only be removed with surgical, saline or laser procedures, and that any effective removal may leave permanent scarring or disfigurement.
*
I understand that the finished tattoo may vary somewhat in appearance, colour and/or from the paper or other drawing or photographic image which the tattoo design is based. That this tattoo treatment is an invasive procedure and that there is potential for discomfort during the procedure and during the healing process and that upon completion of the procedure, there may be swelling and redness of the skin, which will subside within 1-4 days dependent on lifestyle. In rare cases bruising can occur.
*
That using cosmetics, prolonged exposure to water, excessive perspiration and exposure to the sun may affect the healed result and should be limited for up to two weeks following the infusion process. That the result of the procedure is determined by: Medication / Skin Characteristics (dry/oily/sun-damaged)/ Natural skin undertones / Alcohol intake and smoking / General stress / a compromised immune system / Poor diet / Post procedure care. I agree that any touch up work, due to my negligence, will be done at my own expense.
*
To my knowledge I do not have any physical, mental, or medical impairment or disability that might affect my well-being as a direct or indirect result of my decision to have the procedure done at this time. I am at least 18 years old. I am not under the influence of drugs or alcohol. That I have read AND have/will follow all pre-procedure and post-procedure instructions as provided and explained to me by the practitioner and understand that infection and possible scarring can occur if I do not adhere to the said instructions. I accept responsibility for determining the colour, shape and position of the tattoo as agreed during the course of my consultation, and understand that the design template I choose is a true comparison between what was requested and what was delivered.
*
I understand that I am fully responsible for informing the artists of any Medical History changes/updates at the time of any future appointments. And that by not doing so may affect my results. I realize that with any tattoo service there may be certain risks which must be understood. I will be fully responsible for any and all results which may arise from these beauty services. I do hereby agree to release the artists. from any and all claims or suits for damage, for injuries or complications resulting from any tattoo service provided at the studio. I release its artists, directors, officers, employers, agents, successors and assigns from any claim or liability of any nature or kind, in law or equity, in contract or tort, which I have or may have against any one or all of them.
*
I consent to the taking of "before" and "after" photographs/videos of my procedure to be used for marketing for the artists. I understand that all hand/finger/foot/toe tattoos are going to fade quicker and will need regular touch ups. Touch ups are not included in your tattoo price. I understand there are no refunds for faded tattoos
I CERTIFY THAT I HAVE READ, AND HAVE HAD EXPLAINED TO ME, AND FULLY UNDERSTAND THE ABOVE CONSENT FORM AND THAT I HAVE REQUESTED TO HAVE PERMANENT COSMETIC ENHANCEMENTS AT MY OWN FREE WILL.
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