Consent form
Please fill out each section truthfully.
Name
*
They/them
He/him
She/her
Pronouns
First Name
Last Name
Date
*
-
Month
-
Day
Year
Contact number
*
Email
Area (on the body) being tattooed.
Please select any that apply to you, it’s important to be honest.
*
Skin condition in the area being tattooed which may affect the healing of the tattoo such as eczema/psoriasis.
Prone to dizziness/feinting
Diabetic
Pregnant
Breastfeeding
Suffer with epilepsy
Suffer with a heart condition
Diagnosed with any blood borne virus (e.g. HIV, Hepatitis B, Hepatitis C, Hepatitis D)
None of the above
Please list any medication currently being taken.
Any known allergies.
Signature
*
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