EmeraldBeeTattoo Consent Form
Emery Mackay
Client Information
Full Name
*
First Name
Last Name
Pronouns
Date Of Birth
*
-
Month
-
Day
Year
Date
Age
*
You MUST be at 18+
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Have you eaten in the past 4 hours?
*
Yes
No
Do you have any bloodbourne pathogens, transmittable diseases or recent illness?
*
Yes
No
Are you under the influence of drugs or alcohol? Have you consumed alcohol or other toxins within the past 24 hours?
*
Yes
No
Are you pregnant or nursing?
*
Yes
No
Do you have any skin conditions including, but not limited to acne, scaring (keloid), eczema, psoriasis, freckles, moles, or sunburn in the area to be tattooed that may interfere with said tattoo?
*
Yes
No
Do you have any conditions that may affect the procedure or healing process such as lupus, hemophilia, or diabetes?
*
Yes
No
Have you ingested blood thinners such as aspirin or ibuprofen within the last 24 hours?
*
Yes
No
Do you have any allergies, such as but not limited to, latex, iodine, lidocaine, or adhesives?
*
Yes
No
If you answered yes to any of the above questions, please list any skin conditions, allergies, or medical conditions:
What type of appointment are you looking for?
Introverted
Extroverted
No preference
Acknowledgement and Waiver
*
*
*
*
*
*
*
*
*
*
*
*
*
*
Signature Date
*
-
Month
-
Day
Year
Date
Photo of the front of your drivers license
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Drivers License Number
*
Signature
*
Continue
Continue
Should be Empty: