Tattoo Consent Form
Name
*
First Name
Last Name
Age
Birth Date
*
-
Month
-
Day
Year
Date
Phone Number
*
Email
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Pre-Procedure Questionnaire
Are you under the influence of drugs or alcohol?
*
Yes
No
Are you pregnant or nursing?
*
Yes
No
Do you have a communicable disease?
*
Yes
No
Do you have any skin conditions?
*
Yes
No
Skin conditions (e.g. Rashes, eczema, infection, psoriasis, freckles, etc.)
If yes, please identify the condition.
Please tell about your medical history (e.g. DIabetes, Cardiovascular Disease, Epilepsy, Blood-related disease etc.)
*
If yes, please identify the condition.
Acknowledgment and Waiver
*
I understand that this procedure is a permanent change to my skin and body.
*
I allow my tattoo to be photographed and be used for Tattoo Shop portfolio showcased.
*
I acknowledge that the Tattoo Shop does not offer refund.
*
I do not haven any known allergies or adverse reactions to latex, iodine, pigments, dyes, disinfectants, soaps, metals, or other such product.
*
I indemnify and hold harmless the Tattoo Shop against any claims, expenses, damages, and liabilities.
Other
*
I understand that there may be side effects from this procedure, including swelling, bruising.
*
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.
*
I confirm that the information I provided in this document is accurate and true.
Other
Client Signature
*
Signed Date
*
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: