Tattoo Consent Form

Tattoo Consent Form
Submission Date

MonthDayYear
Date
Legal Name

First NameLast Name
Preferred Name
Pronouns
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth
Please Upload a Photo of the Front of Your ID or Driver's License

Cancelof
Do you have diabetes?

YesNo
Do you have hemophilia?

YesNo
Do you have narcolepsy?

YesNo
Do you have skin sensitivities to adhesives or latex?

YesNo
Do you have skin lesions?

YesNo
Do you have a skin disease (psoriasis, eczema, etc.)?

YesNo
Do you have epilepsy, seizures or a history of fainting?

YesNo
Do you have a skin sensitivity to soaps or disinfectants?

YesNo
Are you currently pregnant or breastfeeding?

YesNo
Do you have any allergies such as to metals, soaps, cosmetics, or alcohol?

YesNo
Do you have any condition that requires you to take medications such as anticoagulants that thin the blood or interfere with blood clotting?

YesNo
Are you on any antibiotics?

YesNo
Do you have any other medical or skin condition that may affect the outcome of this procedure?

YesNo
If you answered yes to any of the above, please explain:
Have you eaten in the last 3 hours?

YesNo
I understand that a tattoo is considered permanent and may only be removed with a surgical procedure.

I understand that any effective application or removal of a tattoo may leave scarring

I am the person on the legal ID submitted as proof that I am at least 18 years of age.

I am not under the influence of alcohol or drugs and am voluntarily submitting myself to receive a tattoo without duress or coercion.

I acknowledge the medical information I provided complete and true to the best of my knowledge.

All questions about the tattoo procedure have been answered to my satisfaction, and I have been given written aftercare instructions for the tattoo I am about to receive.

I understand the restrictions associated with this body art procedure as explained by the technician.

I am aware of the risk of infection and am aware of the signs and symptoms.

I will seek professional medial attention if signs or symptoms of infection occur.

I agree to follow all instructions concerning the care of my tattoo and any touch-ups needed due to my own negligence will be at my own expense.

I understand that there is a chance that I could feel lightheaded or dizzy during or after being tattooed.

I will alert my artist immediately in the event I feel lightheaded, dizzy, nauseous, and/or faint before, during, or after the procedure.

I give my permission to have photography and/or videography taken of me and understand that any such materials can be used at the discretion of the technician.
I agree and understand
Design to be tattooed:
Location on my body to be tattooed:
I agree that I have been fully informed of the risks of body art including, but not limited to infection, scarring, and allergic reactions to items associated with the body art procedure. I understand the tattoo is considered permanent, that it can only be removed with a surgical procedure. I understand the technician shall not perform a body art procedure if the client fails to complete or sign the Tattoo Consent and Health Disclosure form. I understand that the Technician may decline to perform a body art procedure if the client has any identified health conditions or may decline to perform a body art procedure for any reason. I understand that there are no refunds for the procedure. I assume all risks associated with the Tattoo Procedure and would like to proceed with application of said procedure.
I agree and understand
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Artist: Emilie Robinson

LIC 311221
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Tattoo Consent Form

Artist: Emilie Robinson