Tattoo Consent Form

Tattoo Consent Form

Please submit prior to your appointment at Tiny Trace Studio - TTS is located at 4030 hickory blvd, granite falls, nc 28630
Today’s Date*

MonthDayYear
Date
Name*

First NameLast Name
Email
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Appointment Date*

MonthDayYear
Date
Date of Birth*

MonthDayYear
Date
Age*
Gender
ID state of Issue and ID Number*
Design and placement*
How did you hear about Tiny Trace Studio?
Have you been to Tiny Trace Studio in the Past?*

YesNo
To ensure the safety of both clients and staff, please indicate if you have been diagnosed with any blood-borne infectious diseases that may pose a risk during tattoo procedures (e.g., HIV, Hepatitis B, Hepatitis C, Herpes, etc.). This information will be kept confidential and is requested solely to maintain safe and sanitary conditions in accordance with health regulations.*

YesNo
If yes, please state your potential infectious disease below (if no please state N/A)*
Are you prone to keloid scarring? If Yes, please explain the location & cause of your scarring.
Do you have or have you had an history of any bleeding disorders, auto-immune disorders, epilepsy, diabetes, shingles, or history of poor wound healing? If Yes, please explain in detail.
Do you have any allergies to dyes, metals, skin care products, lidocaine, epinephrine, latex, any natural oils (orange oil, coconut oil) or medications? If Yes, please list below.
Please list any current medications you are taking.
Do you have any skin conditions (eczema, seborrheic dermatitis, rosacea, alopecia, psoriasis, or trichotillomania?) Please list below.
Have you ever been diagnosed with cancer, or recently undergone chemotherapy? Do you have any additional conditions or health diagnosis that you are undergoing treatment for? If yes, Please explain.
Are you pregnant or breastfeeding?*

YesNo
Consent - Please read all and check to confirm that you agree.*

I am at least 18 years oldI must avoid blood thinners such as aspirin, advil, fish oils, vitamin E supplements, marijuana and alcohol for at least 3 days prior to my treatment.I do not have any bleeding disorders, uncontrolled diabetes, auto-immune disorders, history of keloid scarring, or poor wound healing.The following may negatively effect my results if done within 2 weeks prior to my treatment : laser treatments / chemical peels / Retin-A use / Retinol product use / sun tanning or tanning beds / Injections of Botox, Dysport, Restylane, Juvaderm in the treatment area.I am not pregnant or nursing.I am actually reading these statements.I am not under the influence of drugs or alcohol, nor will I be at the time of my treatment.I agree to follow my Aftercare instructions I am given by my technician.I release any artist working for or renting space at Tiny Trace Studio of all claims for injury that may occur as a result of this treatment.Cancellation Policy : I understand that my booking deposit is NON-REFUNDABLE. The deposit is applied to the cost of treatment, and is only transferrable if appointment change is made within 12 hours notice of scheduled appointment. I understand that an additional $75 cancellation fee will be charged if appointment is cancelled or rescheduled less than 12 hours in advance and/or for no shows. I understand that I can only reschedule my appointment ONCE without forfeiting my deposit.The cost range for treatment has been disclosed to me and I understand that payment is due at the time services are rendered.I agree to contact my technician directly with any concerns or complaints & will refrain from slander of any form on social media or any other media outlet.I fully understand the questions, terms, and conditions of this agreement and believe I have sufficient information to give this informed consent.I understand before/after photos will be taken to document my procedure and may be used for advertising.I agree that this form indicates my consent for tattoos only on my procedure date. It is my responsibility to inform my technician of any medical history changes or medications being taken if changed between appointments.I certify that this Disclosure & Release Agreement was completed by me & that all entries & information are true & complete to the best of my knowledge.In conclusion: I declare that I give my full consent to the tattooing being carried out by Tiny Trace Studio and that I have the potential of complications due to this procedure including but not limited to infection and swelling. I agree to use that aftercare instructions that are provided to me and that any complications due to poor aftercare is due to my own fault. I will not hold my studio or artist at fault due to a potential complication. I agree that once the design and placement are confirmed, the artist is not responsible for any later regret and I cannot change the design, placement, or size once the tattoo has begun. Changing the design on the day of the appointment could result in an additional $50 deposit. I confirm that the above information provided by me for this consent form is correct to the best of my knowledge and that I am over the age of consent for this procedure (18 years old). I am not currently under the influence of drugs and/or alcohol.
Client Signature
Should be Empty: