La Rosa Tattoo
693 14th Street, San Francisco, CA 94114
Consent Form
Client Information
ID Name
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First Name
Last Name
Preferred Name
First Name
Last Name
Pronouns
Who is your artist?
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Age
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Date of Birth
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
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Area Code
Phone Number
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
By clicking the box below, I agree:
I am at least 18 years old.
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Yes
No
Have you eaten in the last two hours?
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Yes
No
Are you under the influence of any drugs or alcohol? If yes, please tell staff or your tattoo artist.
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Yes
No
Do you have any known allergies or adverse reactions to latex, iodine, pigments, dyes, disinfectants, soaps, metals, antibiotics, or other such products? If yes, please tell staff or your tattoo artist.
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Yes
No
Are you pregnant or breast-feeding? If yes, please tell staff or your tattoo artist.
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Yes
No
N/A
Do you understand that reactions to pigments are still possible, even after the tattoo has healed?
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Yes
No
Are you taking blood thinners or any antibiotics? If yes, please let artist know.
Yes
No
Do you understand the permanent nature of receiving body art that may result side effects from this procedure, including bruising, swelling, or scarring?
*
Yes
No
Do you have any conditions that compromise your immune system? If yes, please tell staff or your tattoo artist.
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Yes
No
Do you suffer from hemophilia, epilepsy, narcolepsy, dizziness, fainting, or any form of seizure causing condition that could interfere with the procedure? If yes, please tell staff or your tattoo artist.
*
Yes
No
Are you currently on any medications? If yes, please talk with your artist about any medications you may be taking.
Yes
No
Do you have any medical conditions, blood disorders, or bloodborne illnesses (such as Hepatitis B, Hepatitis C, history of herpes at the tattoo area, etc.) that we should be aware of to ensure your safety during the tattoo process? If yes, please inform your artist.
Yes
No
Do you have any upcoming medical or dental procedures? If yes, please discuss with your artist.
Yes
No
Do you understand that tattoo aftercare is your sole responsibility?
*
Yes
No
Do you give consent to La Rosa Tattoo, LLC the use of photography which may include yourself or parts of your body for marketing and social media purposes? If no, please tell staff or your tattoo artist.
*
Yes
No
Skin conditions (e.g. Rashes, eczema, infection, psoriasis, freckles, etc.)
If yes, please identify the condition.
Acknowledgment and Waiver
Please read and acknowledge:
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I acknowledge that getting a tattoo involves inserting pigment into the skin using sterile needles, which may cause mild discomfort, redness, and swelling during and shortly after the procedure. Once completed, the area will be cleaned and covered with a protective bandage to prevent contamination. In the following days, the tattoo may feel tender and begin to peel or lightly scab as it heals. Proper aftercare—keeping the area clean, moisturized, and out of direct sunlight—is essential for optimal healing and color retention. If you experience excessive redness, swelling, or discharge, contact your artist or a healthcare provider for guidance.
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I acknowledge that both written and verbal instructions regarding risk, outcome, and aftercare were given to me
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I understand that if I have any skin treatments, laser hair removal, plastic surgery or other skin altering procedures, it may result in adverse changes to my tattoo.
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I acknowledge that La Rosa Tattoo does not offer refunds.
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I consent to any actions or conduct of the representatives and employees of the tattoo shop, necessary to perform the procedure.
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I understand that I need to take care of the tattoo by following the instructions given to me by the staff of La Rosa Tattoo, LLC.
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I understand that infection is possible if I do not follow the instructions given to me regarding the aftercare of my tattoo.
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I understand that tattooing is an elective procedure and I consent to the work done by the tattoo artist.
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I understand that there are no FDA approved inks.
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I agree that touch up work needed due to my own negligence will be at my own expense.
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I understand the potential risks associated with a body art procedure. I still wish to proceed with the body art application, and I assume any and all risks that may arise from body art
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I confirm that the information I provided in this document is accurate and true.
Take PHOTO or upload IMAGE from files of your photo ID (Must be 18 years old)
Client Signature
*
Signed Date
*
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Submit
Should be Empty: