• Client Information

  • Date of Birth*
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  • Pre-Procedure Questionnaire

  • Is this your first time visiting our shop?*
  • Have you ever been tattooed before?*
  • Are you under the influence of drugs or alcohol?*
  • Are you pregnant or breast feeding?*
  • Do you have a heart condition?*

  • Are you a hemophiliac?*
  • Do you get keloids?*
  • Are you epileptic?*
  • Do you have diabetes?*
  • Do you have a tendency to faint?*
  • Are you allergic to witch hazel*
  • Are you allergic to Latex*
  • Are you allergic to Adhesives*
  • Are you allergic to Pigment/Ink*
  • Are you allergic to Lavender*

  • I have been fully informed of the inherent risks associated with the process of getting a tattoo and the importance of proper aftercare and healing of a tattoo. I fully understand that these risks, known and unknown, can lead to injury, including but not limited to scarring, infection, difficulties in detecting melanoma, allergic reactions to tattoo pigment, latex gloves, and/or soap. I also state that I have not excluded any important health conditions that I have had or may have. I have been informed of the potential risks associated with getting a tattoo, yet I wish to proceed with the tattoo application and I freely accept and expressly assume any and all risks that may arise from tattooing.

    Therefore, I hereby release any and all persons representing Blessed Ink from all responsibility. I accept any and all responsibility myself for the consequences that might stem from my decision to have any tattoo done by a Blessed Ink artist. I agree to not sue Blessed Ink for damages from my decision to have any tattoo work. I agree for myself, heirs and legal representatives to hold Blessed Ink harmless of all damages, actions, causes of action, claim judgements, costs of litigation, attorney's fees and all other expenses which might arise from my decision to have any tattoo related work done by Blessed Ink. I hereby acknowledge that by signing this agreement, I certify that all information provided is true.

  • Please indicate your artist
  • Date of Appointment
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