Body Tattoo Request Form

Body Tattoo Request Form
Please fill out this form to the best of your ability. If you're having any difficulty completing this form, please contact viecoolstudio@gmail.com.
Client Information
Name

First NameLast Name
Age
This service is only available to guests of 18+ years old.
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearPlease enter a valid date.
Phone Number
Example: (000) 000-0000Format: (000) 000-0000.
Email
example@example.com
Pronouns

Appointment Details
Type of appointment
If booking for a flash, please include the design reference(s)
Example: EF1
Please upload a picture of the desired design

If booking for a flash, you can upload a screenshot of the design.
Cancelof
If booking for a custom, please add a description of the design
Add as many details as possible
Desired placement
Indicate your desired placement for the tattoo(s)
Desired size
Indicate your desired size for the tattoo(s)
Have you had body tattooing before?

Existing Conditions
Are you currently taking any medications?
What are the medications you are currently taking and what is their purpose?
Do you have any allergies?
Specifically, do you have any allergies to numbing agent components such as lidocaine and ephenylephrine?
Please list down your allergies below (e.g. latex, tattoo ink of a certain colour, alcohol, etc.)
Are you pregnant?
Are you breastfeeding?

Please check below if you have the following medical conditions:

Rows	Yes	No	Remarks
Cancer
Hyperpigmentation
Keloid
Hemophilia
Diabetes
Hepatitis
Tuberculosis
Epilepsy
Anemia
HIV positive
Heart conditions (including pacemaker)
Auto-Immune condition
Venereal disease
Asthma
Iron deficiency anemia
Radiation therapy or chemotherapy
Glaucoma
Skin disorder (including rashes, eczema, infection, psoriasis)
Organ transplant
Other

Existing Conditions