Paramedical Tattoo Consent Form
This is a legal document. Please read carefully
Client Information
Full Name
First Name
Last Name
Age
Date of Birth
-
Month
-
Day
Year
Date
Date of Appointment
-
Month
-
Day
Year
Date
Phone Number
*
-
Area code
Phone Number
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Pre-Procedure Questionnaire
Have you consumed alcohol or other intoxicants in the last 24 hours?
Yes
No
FEMALE ONLY: Pregnancy or Nursing?
Yes
No
Do you have a communicable disease?
Yes
No
Are you at risk for fainting, vomiting, and infection including bacterial endocarditis due to a heart condition?
Yes
No
Skin conditions (e.g. Rashes, eczema, infection, psoriasis, freckles, etc.)
If yes, please identify the condition.
List any medications you're currently using that could interfere with your tattoo session such as anticoagulants that could thin or interfere with blood clotting.
Please tell us about your medical history (e.g. DIabetes, HIV, Hemophilia, Cardiovascular Disease, Epilepsy, Seizures, Narcolepsy, Fainting, Blood-related disease etc.)
If yes, please identify the condition.
Please tell us about any history of allergies or any adverse reactions to pigments, dyes, or other sensitivities.
If yes, please identify the condition.
Acknowledgment and Waiver
Please tick bellow to confirm you have read and fully understand the following
*
I understand that this procedure is a permanent change to my skin and body. Results are not guaranteed, but most clients see a 20%-90% in the first session. More sessions may be required to achieve desired results.
*
I allow my tattoo to be photographed and be used for Studio Illumi portfolio including but not excluded to social media. Face will not be included in photos unless approved via written consent by client.
*
I acknowledge that Studio Illumi does not offer refund.
*
I agree that the studio does not have a way of identifying if I am allergic to the elements or ingredients that will be used for my tattoo.
*
I understand that I need to follow the aftercare program to achieve max results. Failure to do so could result in little to no improvements.
*
I understand that I might get an infection if I don't follow the instructions given to me in regards of taking good care of my tattoo.
*
I indemnify and hold harmless Studio Illumi against any claims, expenses, damages, and liabilities.
*
I confirm that the information I provided in this document is accurate and true.
Signed Date
-
Month
-
Day
Year
Date
Client Signature
Submit
Submit
Should be Empty: