Lizz Hell Consent Form
Full Name
*
First Name
Last Name
Date of birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
County
Post code
Email
*
example@example.com
Phone number
*
Are you under the influence of alcohol or drugs or used them in the past 24 hours? If so please make me aware.
*
Yes
No
Do you have a communicable disease? Eg Lymes, HIV, Hepatitis etc.
*
Yes
No
Are you pregnant or nursing?
*
Yes
No
Do you have any skin conditions? If yes, please provide details in the section below and let me know. If not, please write ‘N/A’.
*
Do you have any allergies? If yes, please provide details in the section below and let me know. If not, please write ‘N/A’.
*
Do you have any other medical history that I should be aware of? Eg fainting, diabetes, epilepsy, cardiovascular disease, blood related disease etc. Please let me know how this could effect your appointment.
*
I understand that this procedure is a permanent change to my skin and body. I agree that Lizz Hell does not have a way of identifying if I am allergic to the elements or ingredients that will be used for my tattoo. I identify and hold harmless Lizz Hell against any claims, expenses, damages and liabilities. 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 acknowledge that Lizz Hell nor the tattoo studio offers refunds.
*
Yes
I consent to my tattoo being photographed and used for the artists portfolio to be showcased online. If no, please tell me during your appointment.
*
Yes
No
I confirm that the information I provided in this document is accurate and true.
*
Yes
Date
*
-
Month
-
Day
Year
Date
Signature
*
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