Tattoo Consent Form
Client Information
Name
*
First Name(s)
Last Name(s)
Pronouns
eg. They/Them
Age
*
Date of Birth
*
-
Day
-
Month
Year
Date
Phone Number
*
Format: 00000000000.
Email
*
example@example.com
Address
*
Address Line 1
Address Line 2
City
County
Post Code
Emergency Contact Information
Name
*
First Name
Last Name
Relation
*
eg. housemate
Phone Number
*
Format: 00000000000.
Pre-Procedure Questionnaire
Are you pregnant or nursing?
*
Yes
No
Are you under the influence of drugs or alcohol?
*
Yes
No
Are you prone to fainting?
*
Yes
No
Do you have any communicable diseases?
*
Yes
No
Do you have any skin conditions?
*
Yes
No
Skin conditions (e.g. Rashes, eczema, infection, psoriasis, scarring, etc.)
*
If you have any skin conditions are you comfortable knowing this may affect healing?
*
Yes
No
Do you have any known allergies?
*
Yes
No
Please list any known allergies
*
Any relevant medical history (e.g. high/low blood pressure, diabetes, cardiovascular disease, epilepsy, haemophilia, hepatitis etc.)
Please list any medications you are currently taking
Acknowledgment and Waiver
*
I understand that this tattoo will alter my appearance and is a permanent change to my skin and body.
*
I acknowledge that the tattoo artist does not offer refunds.
*
I accept that while the risk is low, there is a small chance that I may be allergic to an ingredient or element in a product used during the tattoo process (and have disclosed any known allergies).
*
I accept that the artist does not have a way of identifying if I am allergic to the elements or ingredients that will be used for my tattoo.
*
I will follow the aftercare instructions given to minimise the chance of infection and fall out.
*
I understand that I am at risk of infection if I do not follow the aftercare instructions given.
*
I indemnify and hold harmless S. Johnston and the tattoo studio against any claims, expenses, damages, and liabilities.
*
I confirm that the information I have provided in this document is correct to the best of my knowledge.
I allow my tattoo to be photographed and used in the tattoo artist’s portfolio.
Signed Date
*
-
Day
-
Month
Year
Date
Client Signature
*
Submit
Should be Empty: