Tattoo Consent Form
Please read the following consent form carefully, sign at the end, and attach a valid photo ID.
Client Information
Please accurately fill out all of the information below
Full Name of the Client
*
First Name
Middle Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact
First Name
Last Name
Medical History
For your safety, please answer honestly
Do you have or have you ever had any of the following?:
*
Heart conditions
Diabetes
Hemophilia/bleeding disorder
Hepatitis
HIV or other bloodborne illness
Epilepsy/seizures
Skin conditions (eczema psoriasis, keloids, etc…)
Allergies (ink, latex, metals, etc…)
Current medications (blood, thinners, antibiotics, etc…)
Pregnant or nursing
None of the above
If “yes” to any, please describe
Consent and acknowledgment
By checking each box, I acknowledge that:
*
I am at least 18 years of age and have provided valid proof of ID.
I am not under the influence of drugs or alcohol.
I do not have any conditions that may interfere with healing or increased risk of inflection of my tattoo.
I have disclosed all relevant medical conditions to my artist
Client Initials:
*
I understand that receiving a tattoo carries risks, including but not limited to: Infection, allergic reaction, scarring or keloid formation, fading or spreading of ink, discomfort and/or pain
*
Yes
Client Initials:
*
I am at least 18 years of age and have provided valid proof of ID.
*
Yes
Client Initials:
*
I consent to the application of the tattoo and any actions or conduct of the representatives and employees of the tattoo shop reasonably necessary to preform the tattoo procedures.
*
Yes
Client Initals
*
I release my tattoo artist and Root + Ritual from any responsibility for complications that may arise from my procedure.
*
Yes
Client Initials
*
I understand the tattoo is permanent and that no guarantees are made regarding the final appearance.
*
Yes
Client Initials:
*
I have received and agree to follow the written aftercare instructions provided.
*
Yes
Client Initials
*
I consent to the application of the tattoo and to have my information securely stored as required by Connecticut law
*
Yes
Client Initials:
*
Photo ID Upload
*
Upload a File
Drag and drop files here
Choose a file
Please upload a photo of your license here.
Cancel
of
I understand that my artist strives to keep the tattoo process as fair and accessible as possible, while also honoring their own needs as both an artist and a small business owner.
*
Yes
I have read and understood this entire form.
*
Yes
All the information on this form is accurate
Yes
Signature of the Client
*
Date
-
Month
-
Day
Year
Date
Photo Media Release (optional )
I consent to photos of my tattoo being taken for the artist’s portfolio, website, or social media.
I do not consent to photos being used publicly
Signature
Submit Consent Form
Submit Consent Form
Should be Empty: