Returning Client Medical Release Form
Numb Skull Tattoo | 272 N Broadway #7, Tooele, UT, 84074 | cumberledge96@gmail.com | 385-630-8430
Name
*
First Name
Last Name
Birth Date:
*
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Month
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Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
I confirm I have previously completed the full Numb Skull Tattoo Medical History & Consent Form, and my information on file is still accurate except for any updates listed below.
*
Yes
Todays Procedure:
Tattoo preformed by Ryan Cumberledge at Numb Skull Tattoo.
Placement for Today's Tattoo
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Arm, Leg, Hand, Etc.
Breif Description for Today's Tattoo
*
Lion, Flowers, Greek Mythology, Etc.
Health Status since last visit
Have you recieved any new medical diagnoses since your last visit?
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Yes
No
If yes, please describe
Have you started or stopped any medications (including blood thinners, antibiotics, steroids, Accutane, or immune medications)?
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Yes
No
If yes, please list:
Have you developed any new allergies (latex, adhesives, metals, inks, medications)?
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Yes
No
If yes, please list:
Are you CURRENTLY experiencing fever, illness, rash, sunburn, or an infection near the tattoo area?
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Yes
No
In thelast 24 hours, have you used alcohol or recreational drugs?
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Yes
No
These MUST be checked for safety:
*
I confirm I have eaten within the last 4 hours.
I confirm I am not under the influence of drugs or alcohol at this appointment.
I understand that undisclosed medical information may increase my risk of complications.
I understand that infection, allergic reaction, scarring, and pigment changes are possible with any tattoo.
I have received and understand aftercare instructions for today’s tattoo.
Consent and Liability release
I understand that this form updates my existing medical history on file. I acknowledge the risks involved with tattoo procedures, agree to follow aftercare instructions, and release Numb Skull Tattoo and its artists from liability associated with any undisclosed or inaccurate information I provide.
Client Signature
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Today's Date
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Month
-
Day
Year
Date
Artist Signature
Today's Date
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Month
-
Day
Year
Date
Submit
Numb Skull Tattoo | 272 N Broadway #7, Tooele, UT, 84074 | cumberledge96@gmail.com | 385-630-8430
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