Tattoo Consent Form
Helianthus Ink
Client Information
Full Name
*
First Name
Last Name
Age
*
Date of Birth
*
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Month
-
Day
Year
Date
Phone Number
*
Pre-Procedure Questionnaire
Are you under the influence of drugs or alcohol?
*
Yes
No
Pregnancy or Nursing?
*
Yes
No
Do you have a communicable disease?
*
Yes
No
Are you sensitive or allergic to band aids, medical tape, skin tape or stickers?
*
Yes
No
Unknown
Skin conditions (e.g. Rashes, eczema, infection, psoriasis, freckles, etc.) Type “N/A” if not applicable.
*
If yes, please identify the condition.
Medical History (e.g. DIabetes, Cardiovascular Disease, Epilepsy, Blood-related disease etc.) Type “N/A” if not applicable.
*
If yes, please identify the condition.
Any known allergies? This includes adhesives, medications, lotions, plants or fragrances? (Put NA if not applicable)
*
Acknowledgment and Waiver
*
I understand that this procedure is a permanent change to my skin and body.
*
I allow my tattoo to be photographed and be used for Studio portfolio showcased.
*
I acknowledge that the Studio 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 take care of the tattoo by following the instructions given to me by the Studio.
*
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 the Studio against any claims, expenses, damages, and liabilities.
*
I confirm that the information I provided in this document is accurate and true.
Signed Date
*
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Month
-
Day
Year
Date
Client Signature
*
Upload identification (ID, DL, Passport)- Required by law
*
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