Numb Skull Tattoo Medical Release Form
Numb Skull Tattoo | 272 N. Broadway Ave. Suite 7. Tooele UT 84074 | cumberledge96@gmail.com | 385.630.8430
Name
*
First Name
Last Name
Birth Date:
*
/
Month
/
Day
Year
Date
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Health History
Please answer the following questions truthfully. Your health and safety are our top priority.
Are you under the influence of drugs or alcohol?
*
Yes
No
Do you have any known allergies (e.g., latex, lidocaine, metals, pigments, dyes, or other skinsensitivities)?
*
Yes
No
If yes. please explain:
Do you have any skin conditions (e.g., psoriasis, eczema, dermatitis, lesions)?
*
Yes
No
If yes. please explain:
Do you have any bloodborne diseases (e.g., Hepatitis B, Hepatitis C, HIV)?
*
Yes
No
Do you have any heart conditions or take blood thinners?
*
Yes
No
Are you currently taking any medications that may affect blood clotting (e.g., aspirin,anticoagulants)?
*
Yes
No
If yes, please explain:
Do you have any medical conditions that might affect the healing of the tattoo (e.g., diabetes,immune disorders, hemophilia)?
*
Yes
No
If yes, please explain:
Do you have any skin sensitivities (e.g., sensitive to soap or disinfectants)?
*
Yes
No
If yes, please explain:
Do you have a history of epilepsy, seizures, fainting or narcolepsy?
*
Yes
No
If yes, please explain:
Are you pregnant or nursing
*
Yes
No
Acknowledgment and Release
I acknowledge by signing this release form that I have been given the full opportunity to ask any and all questions I might have about obtaining a tattoo from Ryan Cumberledge at Numb Skull Tattoo. All my questions have been answered to my full satisfaction. I specifically acknowledge that I have been advised of the facts and matters set forth below.
I agree as follows:
*
I acknowledge that a tattoo involves inserting pigment into the skin and that it is a permanent change to my appearance.
I understand that tattooing is an art form and that there may be some variation in the design and color.
I understand that the tattooing procedure may involve some pain and discomfort.
I have been informed of the potential risks associated with getting a tattoo, which include but are not limited to infection, scarring, allergic reactions, and dissatisfaction with the final result.
I have received aftercare instructions and understand that proper aftercare is crucial to prevent infection and ensure proper healing of the tattoo.
I do not have any medical conditions that would impair my ability to receive or heal from thistattoo, or I have disclosed any conditions to the tattoo artist.
I release Numb Skull Tattoo, its owners, agents, and employees from all liability for any injury, loss, or damage that may result from the tattooing process.
By signing below, I certify that the information I have provided in this form is accurate and complete, and I consent to the tattooing procedure under the terms described above.
Client Signature:
*
Todays Date:
*
-
Month
-
Day
Year
Date
Artist Signature:
Todays Date:
-
Month
-
Day
Year
Date
Emergency Contact:
Emergency Contact Name:
*
First Name
Last Name
Relationship to client:
*
Emergancy Client Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Submit
Numb Skull Tattoo | 272 N. Broadway Ave. Suite 7. Tooele UT 84074 | cumberledge96@gmail.com | 385.630.8430
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