Eyebrow Tattoo Consent Form
Your Name
*
First Name
Last Name
Are you over 18 years old? An ID will be required the day of your appointment.
*
Yes
No
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Emergency Contact Name & Phone Number
*
Pre-Procedure Questionnaire
Do you have an existing eyebrow tattoo?
*
Yes
No
Are you taking any blood thinning medicine?
*
Yes
No
Are you pregnant or nursing?
*
Yes
No
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
*
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Month
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Day
Year
Date
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