Tattoo Consent Form
Client Information
Name
*
First Name
Last Name
Age
*
Birth Date
*
-
Month
-
Day
Year
Date
Phone Number
*
Format: (000) 000-0000.
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
FEMALE ONLY: 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 acknowledge by signing this release form that I have been given the full opportunity to ask any and all questions I might havea bout obtaining a tattoo from Placasos. I acknowledge that all 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 below, and I agree as follows:
I understand that this procedure is a permanent change to my skin and body.
I grant permission for the tattoo artist and their studio to take photographs of the tattoo for promotional purposes while keeping my personal information confidential.
I acknowledge that the Tattoo Studio does not offer any refund.
I agree that the studio does not have a way of identifying if I am allergic to the elements or ingredients that will be used for my tattoo.
I understand that I need to take care of my tattoo by following the instructions given to me by the Tattoo Studio.
I understand that I might get an infection if I don't follow the instructions given to me in regards of taking good care of my tattoo.
I indemnify and hold harmless the Tattoo Studio against any claims, expenses, damages, and liabilities.
I understand I have to give a 24 hour notice if I need to cancel or reschedule.
I understand I have to arrive 10 minutes early to my scheduled appointment.
I understand tattoo studios are not a place for children. Please arrange for childcare before you come to your scheduled appointment.
I understand a NON-REFUNDABLE deposit of $50 is required to book my tattoo appointment. Deposits go towards the final cost. Appointments will not be held or made without a deposit. This is also good for one rescheduling if needed be. Please submit your deposit through Zelle (336-775-6420) once your booking date has been confirmed.
I understand I will lose my deposit after my second cancellation and I will have to submit another deposit to book another tattoo appointment.
I confirm that the information I provided in this document is accurate and true.
I have been fully informed of the risks of tattooing including but not limited to infection, scarring and allergic reactions to tattoo pigment, latex gloves, and antibiotics. Having been informed of the potential risks associated with getting a tattoo, I still wish to proceed with tattoo application and I assume any and all risks that may arise from tattooing.
Client Signature
Signed Date
-
Month
-
Day
Year
Date
Submit
Submit
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