Tattoo Consent Form (English)

Tattoo Consent Form
Your Name*

First NameLast Name
Are you over 18 years old? An ID will be required the day of your appointment.*

YesNo
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Emergency Contact Name & Phone Number*
Pre-Procedure Questionnaire
Are you taking any blood thinning medicine?*

YesNo
Are you pregnant or nursing?*

YesNo
Please include any notable conditions about your medical history (Diabetes, CardiovascularDiseases, Hepatitis, Hemophilia, HIV-AIDS, Epilepsy, Blood-related disease, Seizures, Fainting, etc)*
Do you have any skin conditions? Please note any skin conditions, such as but not limited to: acne, scarring (Keloid), eczema, psoriasis, freckles, moles, or sunburn in the area to be tattooed:*
Acknowledgment and Waiver
I acknowledge by signing this agreement that I have been given the full opportunity to ask any questions that I might have about the obtaining of a tattoo, and that all of my questions have been answered to my satisfaction. I specifically acknowledge I have been advised of the facts and matters set forth below, and I agree as follows: (if any of these are not checked, please confirm with your artist, as you might not be able to proceed with the 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 wellbeing as a direct or indirect result of my decision to have a tattoo.I am the person on the legal ID presented as proof that I am at least 18 years of age. I have truthfully represented to my tattooer that the obtaining of a tattoo is by my choice alone. I consent to the application of the tattoo and to any actions or conduct of the representative and employees of the tattoo shop reasonably necessary to perform the tattoo procedure.I acknowledge the information I provided in the medical questionnaire is complete and true to the best of my knowledge.I understand there is a possibility of getting an infection as a result of receiving body art. I will seek professional medical attention if signs and symptoms of infection occur.I acknowledge that Diana Pantoja does not offer refunds.I acknowledge that 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 understand that I need to take care of the tattoo by following the instructions given to me by the artist.I indemnify and hold harmless Diana Pantoja against any claims, expenses, damages, and liabilities.I give permission to use of my photos for the purpose of marketing. My pictures may appear in print or online.If I have any condition that might affect the healing of this tattoo, I will advise my tattoo artist before the procedure.I am not under the influence of alcohol or drugs.
Client Signature*
Signed Date*

MonthDayYear
Date
Should be Empty:

Tattoo Consent Form

Pre-Procedure Questionnaire

Acknowledgment and Waiver