CONSENT FORM
Customer Information
Please complete this in full before coming in for your appointment. Failure to complete each section may result in cancelling/rebooking your appointment.
Full Name
*
First Name
Last Name
Age
*
If you are 25 or under please bring photographic ID (we are only able to accept passport or drivers licence) to your appointment as we will need to keep a copy with your form.
Date of Birth
*
/
Day
/
Month
Year
Date
Phone Number
*
-
Area Code/First Five Digits For Mobile
Phone Number
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
Town
County
Post Code
Pre-Procedure Questionnaire
Medical advice should be sought in any case of doubt as to whether procedure is suitable. (If any question is answered ‘Yes’ procedure may need to be reviewed whilst medical advice is obtained).
Do you suffer from any heart conditions (e.g. prosthetic heart valve/ heart valve disease/ angina/ blood pressure problems)?
*
Yes
No
Do you suffer from epilepsy?
*
Yes (please specify how it is controlled)
No
Other
Do you suffer from haemophilia/ other clotting disorders?
*
Yes
No
Do you suffer from any known blood borne virus (E.g. Hep B, Hep C, Hep D, HIV)?
*
Yes (please specify in other)
No
Other
Do you suffer from diabetes or lupus
*
Yes
No
Suffer from any problems with skin healing in the past e.g. psoriasis, eczema?
*
Yes
No
Other
Suffer from any ‘lumpy’ raised scars (keloid)?
*
Yes
No
Suffer from any known allergic responses e.g. plasters/creams/metals/iodine/shellfish/latex/food stuffs/other?
*
Yes
No
Other
Do you take any prescribed medication regularly (especially any anticoagulants such as Warfarin or high dose Aspirin or any immuno- suppressants such as steroids?
*
Yes
No
Other
Are you/could you be pregnant?
*
Yes
No
Any known/previous reaction to dye pigments?
*
Yes
No
Which artist are you booked in with?
*
Pinky
Red
Alan
Katie
Ellie
Appointment Date
*
/
Day
/
Month
Year
Declaration
I declare that I give my full consent to tattooing being carried out by the aforementioned practitioner.
*
Yes
I understand that I need to take care of the tattoo by following the instructions given to me by your tattooist
*
Yes
By consenting to this you are giving us permission to process your personal data specifically for the purpose identified. Consent is required for Black Hope Tattoo Limited to process your personal data, but it must be explicitly given. We will not pass on your personal data to third parties.
*
Yes
No
Customer Signature
*
I confirm that the information I provided in this document is accurate and true
Submit
Artist Signature - Please leave blank for artist
Please leave blank for artists signature
Should be Empty: