Tattoo Consent Form

Licensed tattoo artist

Address will be provided same day as appointment.

Chelly : +1 347-943-4832
Client Information

Please fill out the information below to the best of your knowledge
Full Name

First NameLast Name
Age
Date of Birth

MonthDayYear
Date
Phone Number

Area CodePhone Number
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Tattoo Description
Please describe your tattoo in detail. Size, placement, color, ect.
Body Location of Tattoo
Appointment Date and Time
Date and time you, and your artist have agreed upon.
Who is your artist?
Health Questionnaire

Please select all that apply to you
Do you have any allergies such as:

Other
Diseases:

Other
Overall Health

Other
Emergency Name and Phone Number
(Optional)
Are you currently on any medication? Please list:
(Optional, but encouraged)
Do you have other Tattoos?
If so how many?
Acknowledgment and Waiver

By completing and signing this form, I acknowledge that I have been given the full opportunity to ask any and all questions which I might have about obtaining a tattoo from Dick's Tattoo Parlor, and that all of my questions have been answered to my full and total satisfaction. I specifically acknowledge that I have been advised of the facts and matters set forth, and I agree as follows:
I have truthfully represented to CHELLYWORLDINK that I am over the age of eighteen (18).
I acknowledge that it is not reasonably possible for the representatives and employees of CHELLYWORLDINK to determine whether I might have an allergic reaction to the dyes, pigments or processes used in my tattoo, and I agree to accept the risk that such a reaction is possible.
I acknowledge that I have advised my tattoo artist Chelsea of any condition that might affect the healing of this tattoo. I do not have medical or skin conditions such as but not limited to: acne, scarring (keloid), aczema, psoriasis, freckles, moles, or sunburn in the area to be tattooed that may interfere with said tattoo. If I have any type of infection or rash anywhere on my body, I will advise my tattooer.
I am not pregnant or nursing.
I am not under the influence of alcohol or drugs.
I acknowledge that infection is always possible as a result of obtaining a tattoo, particularly in the event that I do not take proper care of my tattoo. I have received aftercare instructions and I agree to follow them while my tattoo is healing. I agree that any touch-up work needed, due to my own negligence, will be done at my own expense. This includes sun and ultraviolet frequency damage.
I acknowledge that infection is always possible as a result of obtaining a tattoo, particularly in the event that I do not take proper care of my tattoo. I have received aftercare instructions and I agree to follow them while my tattoo is healing. I agree that any touch-up work needed, due to my own negligence, will be done at my own expense. This includes sun and ultraviolet frequency damage.
I acknowledge that CHELLYWORLDINK does not offer refunds.
I acknowledge that a tattoo is a permanent change to my appearance and that no representations have been made to me as to the ability to later change or remove my tattoo. To my knowledge, I do not have physical, mental or medical impairment or disability which might affect my well being as a direct or indirect result of my decision to have a tattoo.
I acknowledge that if my tattoo is a symbol, or something written in a language other than English, that CHELLYWORLDINK are not responsible for what it may or may not mean.
I acknowledge that if my tattoo includes text, that I am responsible for the correct spelling, grammar and punctuation. I have proofed the text before it is applied as a tattoo.
I acknowledge that variations in colour and design may exist between any tattoo as selected by me and as ultimately applied to my body. I understand that if my skin is dark, the colours will not appear as bright as they do on light skin.
I acknowledge the decision for obtaining my tattoo is my own free will and choice. I consent to the location of the tattoo and the performance of the tattoo procedure.
I acknowledge and agree to following any and all instructions provided to me regarding the maintenance of a sanitary environment while I am being tattooed.
I agree that the tattoo design is correctly drawn to my specifications and I agree to allow for artist interpretation of the image.
I agree to immediately notify my tattooer if I feel lightheaded, dizzy and/or faint before, during or after the procedure. Failure to do so releases CHELLYWORLDINK and my tattooer of all responsibility.
I agree that I have not been in contact of Covid-19 and show no signs of being sick.
Signed Date

MonthDayYear
Date
Client Signature
Photo ID

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If you have any questions, feel free to call,text, or email me at chelly.l@icloud.com or @chellyworldink /@Thaturbanchick

Text me at +1 347-943-4832

get ahold of me on IG or through email/phone.

Thanks, ChellyWorldInk
Name

First NameLast Name
Should be Empty:

Client Information

Health Questionnaire

Acknowledgment and Waiver