Tattoo Consent Form

Tattoo Consent Form
Client Information
Name

First NameLast Name
Age
Birth Date

MonthDayYear
Date
Driver's License Number
State Issued
Phone Number
Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Pre-Procedure Questionnaire
Are you under the influence of drugs or alcohol?
FEMALE ONLY: Are you pregnant or nursing?
Do you have a communicable disease?
Do you have any skin conditions?
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 have been fully informed of the inherent risks associated with getting a tattoo. Therefore, I fully understand that these risks, known and unknown can lead to injury including but not limited to: infection, scarring, difficulties in the detection of melanoma and allergic reactions to tattoo pigment, latex gloves and/or soap. Having been informed of the potential risks associated with getting a tattoo procedure and application and freely accept and expressly assume any and all risks that may arise from tattooing.
I WAIVE AND RELEASE to the fullest extent permitted by law any person of Kirby Inked from all liability whatsoever, including but not limited to, any and all claims or causes of actions that I, my estate, heirs, executors or assigns may have for personal injury or otherwise, including any direct and/or consequential damages, which result or arise from the procedure and application of my tattoo, whether caused by the negligence or fault of either Kirby Inked, or otherwise.
I do not suffer from diabetes, epilepsy, hemophilia, heart condition(s), nor do I take blood thinning medication. I do not have any other medical or skin condition that may interfere with the procedure, application or healing of the tattoo. I am not the recipient of an organ or bone marrow transplant or, if I am, I have taken the prescribed preventative regimen of antibiotics that is required by my doctor in advance of any invasive procedure such as tattooing or piercing. I am not pregnant or nursing. I do not have a mental impairment that may affect my judgement in getting the tattoo.
If any provision, section, subsection, clause or phrase of this release is found to be unenforable or invalid, that portion shall be severed from this contract. The remainder of this contract will then be construed as though the unenforable portion had never been contained in this document.
I hereby declare that I am of legal age and have provided valid proof of age and identification and am competent to sign this Agreement.
I HAVE READ THE AGREEMENT, I UNDERSTAND IT, AND AGREE TO BE BOUND BY IT.
Client Signature
Signed Date

MonthDayYear
Date
Should be Empty:

Tattoo Consent Form

Client Information

Pre-Procedure Questionnaire

Acknowledgment and Waiver