Consent Form
Name
*
First Name
Last Name
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Age
*
Birth Date
*
-
Month
-
Day
Year
Date
Date of Appointment:
*
-
Month
-
Day
Year
Date
Pre-Procedure Questionnaire
Have you consumed alcohol or other intoxicants in the last 24 hours?
*
Yes
No
Any allergies to latex, iodine, adhesive, or other products routinely used during tattoo procedure?
*
Yes
No
Are you pregnant or nursing?
*
Yes
No
Have you taken any blood thinners such as aspirin or ibuprofen in the last 24 hours?
*
Yes
No
Do you have a communicable disease?
*
Yes
No
Are you at risk for fainting, vomiting, and infection including bacterial endocarditis due to a heart condition?
*
Yes
No
Please tell us about your medical history (e.g., Diabetes, HIV, Hemophilia, Cardiovascular Disease, Epilepsy, Seizures, Narcolepsy, Fainting, Blood-related diseases, etc.)
*
Please tell us about any history of allergies or any adverse reactions to pigments, dyes, or other sensitives.
*
List any medications you're currently using that could interfere with your tattoo session such as anticoagulants that could thin or interfere with blood clotting.
*
Acknowledgement and Waiver
I Understand that this procedure is a permanent change to my skin and body. Results are not guaranteed, but more clients see a 20%-90% in the first session. More sessions may be required to achieve desired results.
*
Agree
I allow my tattoo to be photographed and be used for the Spiritual Beauty by Kells portfolio including but not excluded to social media. Face will not be included in photos unless approved via written consent by client
*
Agree
I acknowledge that Spiritual Beauty by Kells does not offer refund.
*
Agree
I agree that the studio does not have a way of identifying if I am allergic to the elements or ingredients that will be used for my tattoo. Ingredients include: NUE Pigments: Glycerin, Alcohol, Water, Pigments, C177891, C177492, C177491.NUE Clear: Chamaecyparis Obtusa Leaf Extract, Thiamine Hydrochloride, Pyridoxine Hydrochloride, Cystein, Copper Peptide, Glycine, Chamaecyparis Obtusa Water, Dryopteris Crassirhizoma Extract, Allantoin, Ethylhexyglycerin, Dipotassium Glycyrrhizate, Polyglycery 1-4 Caprate, Pentylene Glycol, Aspalathus Linearis Extract, Proteins Myosin, Kinesin, Collagen, Amino, Acids L-Lysine, L-Glutamine, L-Arginine, L-Leucine, L-Alanine, L-Histanine, Mineral Calcium, Sodium, Potassium, Iron, Zinc. NUE Dilutant: Water, Glycerin, Propylene Glycol.
Agree
I understand that I need to follow the aftercare program to achieve max results. Failure to do so could result in little to no improvement.
Agree
I have already read the Tattoo Aftercare Instructions. Found on spiritualbeautybykells.com - Client Resource Page.
*
Agree
I understand that I need to get an infection if I don't follow the instructions given to me in regard to taking good care of my tattoo.
Agree
I indemnify and hold harmless Spiritual Beauty by Kells against any claims, expenses, damages, and liabilities.
Agree
Signed Date
-
Month
-
Day
Year
Date
Client Signature
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