Echo Esthetics Consent Form

Full Name*

First NameLast Name

Pronouns

Age*

Date of Birth*

Phone Number

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Have you been tattooed before?*

YesNo

Are you currently under the influence of drugs or alcohol?*

YesNo

Are you pregnant or breast-feeding?*

YesNo

Do you have a history of medication use or currently using medication, including being prescribed antibiotics prior to dental or surgical procedures?*

YesNo

Are you on any medications that thin the blood or interfere with blood clotting?*

YesNo

Do you have a history of herpes infection at the proposed procedure site, allergic reactions to latex or antibiotics, hemophilia or other bleeding disorder, or cardiac valve disease?*

YesNo

If applicable, please list any other risk factors for bloodborne pathogen exposure:

Ex: skin conditions, diseases, etc.

Do you have any allergies? If so, please list them here:

Are you a hemophiliac?*

YesNo

Do you get keloids?*

YesNo

Are you epileptic?*

YesNo

Do you have diabetes?*

YesNo

Do you have a tendency to faint?*

YesNo

By signing this consent form, I hereby acknowledge that I am voluntarily choosing to undergo a tattoo procedure. I confirm that I am at least 18 years of age and have provided valid identification. I understand the nature of the tattoo process, including potential risks such as infection, allergic reactions, and scarring, and I accept these risks. I acknowledge that the tattoo artist has explained the procedure, aftercare requirements, and answered any questions I had to my satisfaction. I release the tattoo artist and Echo Esthetics tattoo studio from any liability related to the procedure, including any undesired outcomes. My consent is fully informed, and I understand this decision is permanent. I certify that all information I have provided is true.

Client Signature*

Photo of your ID*

Date of Appointment

Date

Client Information

Pre-Procedure Questionnaire