Ritual Consent Form
Please read the information below to ensure you fully understand the agreements for ritual tattoos.
Client Information
Please fill out all the required fields below
Full Name
*
First Name
Last Name
Date of Birth
*
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Month
-
Day
Year
Date
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
Sacred Agreement
This is a ceremonial space rooted in respect, integrity, and care. By signing this form, you enter into a sacred agreement of mutual respect and responsibility. Ritual tattoos are a collaborative, intentional process. The ceremony belongs to you — I hold space as your artist and guide, but the meaning, integration, and responsibility remain with you.
I have read and acknowledge the above statement
*
Yes
Acknowledgment of Ceremonial and Energy Based Services
I understand that this tattoo session includes ritual or spiritual components (such as meditation, grounding, breath-work, reiki, sound healing, intention setting, etc...) as part of the artists unique creative process.
I acknowladge that:
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I understand that my tattoo artist, Victoria Jackson (Victoria Moon / Root + Ritual) is not a licensed therapist, counselor, medical provider, or mental health professional.
Ritual practices are optional and I may decline any components at any time.
Ritual or energy-based practices are not medical treatment, therapy, or substitute for licensed mental health or medical care.
Any spiritual. energetic, or symbolic meaning of the tattoo is based on personal belief.
Any spiritual, energetic, or emotional experiences that may arise during or after the ritual are my personal responsibility to integrate.
I understand that if I need medical, psychological, or therapeutic support, it is my responsibility to seek licensed professional care.
I understand that I am fully responsible for communicating my boundaries and may accept or decline touch at any time.
I understand that ritual tattoos may include elements of physical touch (such as grounding, energy clearing, or supportive contact). The practitioner will always ask for my consent before any touch occurs.
Client Initials:
Medical and Health Disclosure
Do you have any of the following?
*
Bloodborne diseases (Hepatitis, HIV)
Skin conditions at tattoo site (eczema, psoriasis, open wounds)
Uncontrolled diabetes
History of keloids
Blood-thinning medication
Pregnancy or nursing
NONE of the above
Allergies if any:
Are you currently under the influence of drugs or alchohol?
*
Yes
No
Current Medications if any:
Tattoo Risks & Aftercare:
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I understand that receiving a tattoo involves puncturing the skin, which carries risks including infection, allergic reaction, and scarring.
I will follow the aftercare instructions provided by my artist to minimize risk.
I understand that tattoo ink may fade or blur over time.
I release my artist from liability related to normal risks of tattooing.
Client Initials:
*
Tattoo Consent (CT State Requirements)
Tattooing involves needles, ink insertion, and minor bleeding. Risks include pain, infection, allergic reaction, swelling, scarring, or dissatisfaction with design. I am responsible for following aftercare instructions.
I am 18 years or older:
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Yes
No
I consent to receiving a permanent tattoo and understand the associated risks.
*
Yes
No
I have received aftercare instructions and fully understand that improper aftercare can affect healing and results of my tattoo
*
Yes
No
Client Initials:
Artist’s Creative & Ritual Process
Ritual tattooing includes intuitive or symbolic elements and artistic interpretation within the agreed-upon theme.
I understand that the artist retains creative discretion within the agreed direction.
*
Yes
No
I approve the final stencil/design before tattooing begins.
*
Yes
No
Client Initials:
Liability Release
I release Victoria Jackson (Victoria Moon) and Root + Ritual Tattoo & from all liability associated with the tattoo process, ritual components, allergic reactions, infections, emotional responses, or any changes in my body during healing.
I agree to this full release of liability.
*
Yes
No
Client Initials:
Photo/Video Release
Do you give permission for photos/videos of your tattoo or session to be used for social media, website, and portfolio?
Yes, I give permission
No, I do not give permission
Client Full Signature:
Date
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Month
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Day
Year
Date
Final Confirmation
Type a question
I have read and understood this entire form.
All information I provided is accurate.
I consent to receiving a tattoo and participating in any optional ritual elements.
Type option 4
Client Signature
*
Date
*
-
Month
-
Day
Year
Date
Continue
Continue
Should be Empty: