Tattoo Consent Form

Tattoo Consent Form
Please read this form carefully and provide accurate information. This consent form is required by Ontario health regulations to ensure your safety and well-being during the piercing procedure.
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Date
Picture of your Identification / Proof of Age*

License, Passport, Healthcard etc
Cancelof
Emergency Contact Name*
First & Last Name
Emergency Contact Phone Number*
Please enter a valid phone number.
The date of my appointment is:

MonthDayYear
Date
Artist Name:*
Age
I understand that this is a binding contract & I that I will have full opportunity to ask any and all questions about my procedure. I will only proceed with my appointment once all of my questions have been answered to my satisfaction.*

I agree to this statement
I understand that my procedure is permanent, and its removal may be difficult or impossible. I am aware that removal may cause scarring.*

I agree to this statement
I do not / will not have any medical conditions or communicable diseases (including but not limited to diabetes, epilepsy, hemophilia, hepatitis, HIV, AIDS, tuberculosis, COVID19) at the time of my procedure.*

I agree to this statement
I do not / will not have a skin condition that may interfere with the proper healing of my procedure (including but not limited to acne, scarring or keloids, eczema, psoriasis, freckles, moles, or sunburn).*

I agree to this statement
I agree that the tattoo shop and its employees cannot determine if I will have an allergic reaction to any of the products used to complete my procedure. I attest that I have no known allergies, or if I do I have alerted my artist.*

I agree to this statement
I am not / will not be pregnant or breast-feeding at the time of my procedure.*

I agree to this statement
I am not / will not be under the influence of drugs, alcohol, or any narcotic, including but not limited to prescription pharmaceuticals & over the counter medications. I am aware that being under the influence can have an adverse effect on the procedure.*

I agree to this statement
I agree that the artist is not responsible for the meaning, symbolism, placement, or spelling of my tattoo or piercing.*

I agree to this statement
I understand that variations in colour and design may exist between the tattoo art I select and the actual tattoo when it is applied to my body. I understand that over time, the colours and clarity of my tattoo will fade due to sun exposure and the naturally occurring dispersion of pigment under the skin.*

I agree to this statement
I am aware of the possibility of infection with my procedure. I understand that it is my responsibility to follow the aftercare procedures recommended by my artist. My artist makes no claim to the success or validity of the recommended aftercare procedures, they are simply guidelines. I agree to not hold the artist or shop liable for any necessary touch-up work caused by my own negligence.*

I agree to this statement
I agree to release and forever discharge the shop and its employees from any and all claims, damages, or legal actions arising from or connected in any way with my procedure.*

I agree to this statement
The artist can use pictures of my tattoo / piercing / the procedure for marketing and social media.*

I agreeI do not agree
The artist can tag me on social media using the following handle
Example: @theladygs
The artist can email or text me with updates about promotions, discounts and other information pertaining to the business from time to time.*

I agreeI do not agree
Medical History

Leave blank if not applicable
Allergies

LatexMetalsOther
Other:
Please provide details
Medications
Example: Blood thinners
Conditions
Example: Type 1 Diabetes
Other
Any other relevant information pertaining to your medical history or that you would like us to know.
I acknowledge that I have truthfully represented myself to the Muskoka Tattoo Collective and its employees and that I am at least 18 years of age and am competent to sign this agreement. If I am not 18 years of age, my legal guardian is in complete agreement with the conditions set out above and shall sign on my behalf.*

I agree to this statement
Client Signature*

Clear
Today's Date*

MonthDayYear
Date
Signature of Legal Guardian (if applicable)

Clear
Today's Date*

MonthDayYear
Date
Name of Legal Guardian*
Full Name
Relationship of Guardian to Client*
Parent / Grand Parent / Guardian etc
Email of Guardian*
example@example.com
Phone Number of Guardian*
Please enter a valid phone number.
Guardian's Date of Birth*

MonthDayYear
Date
Picture of Guardian's Identification / Proof of Age*

Driver's License / Passport / Health Card etc
Cancelof
STUDIO USE ONLY
INK INFORMATION
Expiries and Lot numbers
CARTRIDGE INFORMATION
Expiries and Lot numbers
Artist Signature*

Clear
Date*

MonthDayYear
Date
YES
Artist Signed?
Should be Empty:

Tattoo Consent Form

Medical History

STUDIO USE ONLY