Returning Client Medical Release Form

Returning Client Medical Release Form

Numb Skull Tattoo | 272 N Broadway #7, Tooele, UT, 84074 | cumberledge96@gmail.com | 385-630-8430
Name

First NameLast Name
Birth Date:

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
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.
Todays Procedure:

Tattoo preformed by Ryan Cumberledge at Numb Skull Tattoo.
Placement for Today's Tattoo
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?
If yes, please describe
Have you started or stopped any medications (including blood thinners, antibiotics, steroids, Accutane, or immune medications)?
If yes, please list:
Have you developed any new allergies (latex, adhesives, metals, inks, medications)?
If yes, please list:
Are you CURRENTLY experiencing fever, illness, rash, sunburn, or an infection near the tattoo area?
In thelast 24 hours, have you used alcohol or recreational drugs?
These MUST be checked for safety:
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
Today's Date

MonthDayYear
Date
Artist Signature
Today's Date

MonthDayYear
Date
Numb Skull Tattoo | 272 N Broadway #7, Tooele, UT, 84074 | cumberledge96@gmail.com | 385-630-8430
Should be Empty:

Returning Client Medical Release Form

Todays Procedure:

Health Status since last visit

Consent and Liability release