54 Tattoo — Consent Form
Please complete this on the day of your appointment before we start. You must be 18+.
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
-
Month
-
Day
Year
Date
Upload a clear photo of your government ID (passport or driving licence)
*
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of
Placement (body area)
*
Approx. size (cm)
*
Description of tattoo
*
Allergies (write “None” if none)
*
Medical conditions (tick all that apply)
*
Diabetes
Epilepsy / Seizure disorder
Heart condition / Blood pressure issues
Immune system disorders
Skin conditions (psoriasis/eczema/dermatitis) on/near the area
History of keloid scarring
Blood-borne infections (HBV/HCV/HIV)
None of the above
Other
If selected any condition above, provide details
Current medications
Pregnancy / breastfeeding
*
Yes
No
Recent procedures on the area (laser/peels/microneedling) in the last 2–4 weeks?
*
Yes
No
Pre-session checklist
*
I have not consumed alcohol or recreational drugs in the last 24 hours.
I have eaten a proper meal and feel well-rested today.
I have not applied fake tan/retinoids/strong exfoliants on/near the area in the last 3–5 days.
I have no sunburn, open wounds, active cuts, or infections on/near the area.
I will follow the aftercare instructions provided.
Today's date and time
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Signature
*
Submit
Submit
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