Tiny Tattoo Fine Line Consent Form
Full Name
*
First Name
Last Name
Contact Number
*
Format: (000) 000-0000.
Email Address
*
example@example.com
Date
-
Month
-
Day
Year
Date
Check the conditions that apply to you or any member of your immediate relatives:
Abnormal Heart Condition
Cancer
Asthma
Diabetes
Abnormal Heart Disease
Fainting Spells or Dizziness
Epilepsy
Hemophilia
Skin Condition (eczema etc)
Stroke
Pregnant or Breastfeeding
HIV
High/Low Blood Pressure
Liver/Kidney Disease
Other
Are you currently taking any medication?
Yes
No
Please list them.
Do you have any medication allergies?
Yes
No
Not Sure
Please list them.
Have you taken any of the following in the last 2 days; Aspirin, Ibuprofen, Coumadin, Alcohol?
Please Select
Yes
No
Have you received chemotherapy or radiation treatment in the last year?
If I have any condition that might affect the healing of this tattoo, I will inform my tattooer. I am not
pregnant or nursing. I am not under the influence of alcohol or drugs.
I do not have medical or skin conditions such as but not limited to: acne, scarring (Keloid) eczema,
psoriasis, freckles, moles or sunburn in the area to be tattooed that may interfere with said tattoo.
If I have any type of infection or rash anywhere on my body, I will advise my tattooer.
I acknowledge it is not reasonably possible for the representatives and employees of this tattoo shop to
determine whether I might have an allergic reaction to the pigments or processes used in my tattoo, and I agree to accept the risk that such a reaction is possible.
I acknowledge that infection is always possible as a result of the obtaining of a tattoo, particularly in the
event that I do not take proper care of my tattoo.
I have received aftercare instructions and I agree to
follow them while my tattoo is healing.
I agree that any touch-up work needed, due to my own
negligence, will be done at my own expense.
I realize that variations in color and design may exist between any tattoo as selected by me and as
ultimately applied to my body.
I understand that if my skin color is dark, the colors will not appear as bright as they do on light skin.
I understand that if I have any skin treatments, laser hair removal, plastic surgery or other skin altering procedures, it may result in adverse changes to my tattoo.
I acknowledge that a tattoo is a permanent change to my appearance and that no representations have
been made to me as to the ability to later change or remove my tattoo. To my knowledge, I do not have a
physical, mental or medical impairment or disability which might affect my well being as a direct or indirect result of my decision to have a tattoo.
I consent to the application of the tattoo and to any actions or conduct of the representatives and employees of the tattoo shop reasonably necessary to perform the tattoo procedure.
I agree to release and forever discharge and hold harmless the Tattooer Suleika Perez-Usher and Flawless Symmetry LLC and all
employees from any and all claims, damages or legal actions arising from or connected in any way with my tattoo, or the procedure and conduct used in his/her tattoo.
Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: