Tattoo Medical History and Consent Form

Date

FULL NAME

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Is there anything I can do to help you feel you more comfortable during our appointment (I’m happy to wear a kn95 mask upon request, for other medical accommodations please reach out to me directly on instagram @juliannainks before completing this form)

Ex. Quiet appointment, extra breaks, sensory needs, anything else

Is there anything about you that you would like me to be aware of (disabilities, mental health, neurodivergence)

No need to disclose, however my practice is a safe and inclusive space for all people, so don’t hesitate to inform me of anything you’d like to share

Do you feel anxiety about speaking up (ie. if you’d like to move the stencil, if you’d like to change an aspect of the design, or if you need a break), would you like extra check ins throughout the process, and/or is this your first tattoo?

If you struggle with communication or people pleasing - please write ‘yes’ and I will check in with you extra. If this is your first tattoo, please write first tattoo

Body Modification (Tattoo) Release Waiver

In consideration of receiving a tattoo from Julianna Reader of Julianna Inks, I agree to the following:

I am informed of the inherent risks associated with getting a tattoo. I fully understand that these risks, known and unknown, can lead to injury, including but not limited to infection / scarring, difficulties in detecting melanoma and allergic reaction to tattoo pigment, gloves, and / or soap. Have been informed of the potential risks associated with getting a tattoo, I still wish to proceed with the tattoo application and I freely accept and expressly assume any and all risks that may arise from tattooing.

Initial here

To wave and release the fullest extent permitted by law the Artist and the Studio from all liability whatsoever for any and all claims or causes of action that my estate heirs executors or assigns may have for personal injury or otherwise including any direct and/or consequential damages which result or arise from the application of my tattoo regardless of the cause

Initial here

Artist and the Studio has given me the full opportunity to ask any and all questions about the application of my tattoo and all of my questions have been answered to my total satisfaction

Initial here

List any medications or supplements that you are taking

List allergies or sensitivities that you may have

Medical history (please check off any and all options that apply to you)

Please write out any medical conditions you have and directly communicate to Julianna as an extra precaution (even if you checked the box above)

I consent in advance to photo reproduction in print or electric form.

ADDRESS

DATE OF BIRTH

Date

EMERGENCY CONTACT

EMERGENCY CONTACT NUMBER

Please attach a photo of your photo ID that includes your name and birth date

GENERAL INFORMATION

DEPOSIT: I require a deposit in order to reserve your appointment date and time. Deposits are final, non-refundable, and due within 24 hours of your consultation. Deposit payments can be made through cash or e-transfer. Once the deposit has been received, you will then receive a confimation of your appointment via text. The deposit amount will be deducted from the final cost of your tattoo once your appointment is complete.

PRICING: The price of your tattoo will vary depending on the design, size, placement and/or intricacy of the design therefore prices will vary per piece. Your final total may change if revisions are made to the idea, design, size, placement, or overall scope of work.

DESIGN: I do not send tattoo designs prior to your appointment. We will go over the design together at the start of the appointment and I am happy to make minor changes for free. Please be descriptive and specific when requesting a design to ensure that major changes will not be necessary

TERMS & CONDITIONS

PAYMENT: The remaining balance will be due on the day of your appointment and can be made through cash or e-transfer only. I do not accept debit or credit cards

RESCHEDULING: I allow ONE date reschedule with at least 48-hour notice. I can try to accommodate one time reschedule for the same date with as much prior notice as possible

Any change to your appointment time after this will forfeit and nullify your original deposit. An additional deposit will be required to reserve a new appointment time

If you are more than 20 minutes late to your appointment without prior notice you will be considered a no-show. If you are a no-show, you forfeit and nullify your deposit.

TIMING: Tattooing can be a lengthy process.
Please allow plenty of time and disclose any same-day engagements you may have in advance.

I hereby declare that I am of legal age 18+ (and have provided valid proof of age) and am competent to sign this Agreement.

I have read this Agreement, I understand it and I agree to be bound by it.

TODAYS DATE

Date

SIGNATURE

Tattoo Medical History Form

Please read and ensure you understand the following statements before checking the box to agree: