TATTOO CONSENT FORM

TATTOO CONSENT FORM
E.b.b. & Flow Creative Space : Sam Brown BAP-TA-10231576

Please fill in form with as much information as possible & initial in the boxes provided after reading to show that you understand each provision. Feel free to ask any questions.
Preferred Name
Pronouns
Address
Phone Number
Email
example@example.com
For this appointment I would like: (circle the letter of the one(s) that feel most applicable):

Quiet time with headphones on or readingSpace to share and be vulnerableCasual chattingExtra consideration and communication of touchOther
Anything else you would like Sam to know about this appointment?
In consideration of receiving a tattoo from Sam L Brown, I agree to the following:
I,Print Name Here
I have been fully informed of the inherent risks associated with getting a tattoo. Therefore, I fully understand that these risks, known and unknown, can lead to injury including but not limited to: infection, scarring, difficulties in the detection of melanoma and allergic reactions to tattoo pigment, latex gloves and/or soap.Having been informed of the potential risks associated with getting a tattoo, I wish to proceed with the tattoo procedure and application and freely accept and expressly assume any and all risks that may arise from tattooing.My artist has given me the full opportunity to ask any question about the procedure and application of my tattoo and all of my questions, if any, have been answered to my total satisfaction.I acknowledge that, while it is rare, it is still possible that the tattoo can become infected, particularly if I do not follow the instructions given to me to care for the tattoo. If this happens, I will let my artist know and contact a medical professional.Variation in color and design may change between the art selected and the final product on my body. I also understand that over time, color and clarity of my tattoo will fade due to unprotected exposure to the sun and naturally occurring dispersion of pigment under the skin.A tattoo is a permanent change to my appearance. If chosen to remove, the means of removal is extensive and often costly and does not guarantee the restoration of my skin in the exact appearance before being tattooed.Any touch up work to the tattoo is not guaranteed to be covered financially by my artist.There is no refund policy on tattoos or deposits made at time of booking.I am not under the influence of any substances, and I am voluntarily consenting to be tattooed without duress or coercion.I am not pregnant or nursing.I release the right to any photography’s taken of me and the tattoo and give consent in advance to any usage of them in the future. (**Please inform Sam if you wish to not be photographed!)I hereby declare I am of legal age (18 years old) and have provided valid proof of age and identification.I acknowledge that I have been given adequate opportunity to read and understand this document.
Do you have any of the following: high blood pressure, diabetes, epilepsy, hemophilia, heart condition(s), nor do I take blood thinning medication? If yes, please select other & specify:

NoOther
Do you have any skin conditions or sensitivities we should know about? If yes please describe
Do you have any allergies? If yes please list below
I have read the agreement, I understand, and give consent to the following procedure.
Printed Name
Signature

Clear
Please upload a photo of your valid identification (must be a non-expired, government issued, photo identification):

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Date

MonthDayYear
Date
Placement location on the body
Brief description of the tattoo including size estimate
Should be Empty: