Tattoo Consent, Waiver & Information Collection Form
Tattooist License Number: 4353846
I acknowledge that all information provided in this form is true, complete, and accurate to the best of my knowledge. I understand that knowingly providing false, misleading, or incomplete information, or withholding relevant information, may constitute an offence and may result in legal action being taken against me.
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I acknowledge and understand the above.
I acknowledge that upon submission, all information and documents provided in this form will be collected and securely stored for legal, regulatory, and professional record-keeping purposes. I understand that all information is treated as confidential and private.I further acknowledge and consent that this information may be disclosed to relevant authorities, including police, courts, or regulatory bodies, if required by law or upon lawful request.
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I acknowledge, understand, and consent to the above.
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Appointment Date
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/
Day
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Month
Year
2 digit day, 2 digit month, 4 digit year
Personal information
Please complete the following personal information questions.
Full Name
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Miss.
Mr.
Mrs.
Ms.
Dr.
Other
Prefix
Date Of Birth
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
You must be 18 years or older to be tattooed in Queensland.
Phone Number
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Format: 0000-000-000.
E-mail Address
Address
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Street Address Line 2
Please take a photo of your valid I.D.
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Medical Information
Please complete the following medical & health information questions. Tick the answers that apply. Multiple answers can be selected.
Are you currently:
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Pregnant
Breastfeeding
Undergoing fertility treatment
None of the above
Do you have or suspect any skin conditions?
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Eczema
Psoriasis
Chronic acne
Keloid scarring
Hyperpigmentation
No skin conditions
Not listed
Do you have any known allergies?
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Please select all conditions that apply to you:
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Diabetes
Epilepsy
Tuberculosis
Hepatitis
HIV/AIDS
Staph/MRSA
Strep
Blood disorder (Haemophilia, etc.)
Heart condition
Herpes
Asthema
Seizures
Anaphylactic allergy
Cancer
Autoimmune disease
None of the above
I have a condition/s not listed
Are you prone to any of the following:
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Fainting or Dizziness
Panic or anxiety attacks
Needle Phobia
None of the above
Other
Relevant medical treatments & medications
Are you currently or will soon be undergoing:
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Cancer treatment
Skin biopsy
Eczema/Psoriasis treatment
Allergy treatment
Acne treatment
Laser treatment
Microneedling or R/F
Chemical skin peels
Planned surgery
MRI scan
None of the above
Other
Have you taken any of the following medications in the past 3 months:
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Blood thinners
Acne medication (Accutane, etc.)
Antibiotics
Steroids
Immunosuppressants
Thyroid medication
None of the above
Are you currently prescribed any medications not listed above? If yes, please list all.
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Are you currently taking any over the counter medications, or herbal remedies? If yes, please list all.
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Have you taken any of the following medications in the past 24 hours:
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Blood thinners
Antibiotics
Nurofen/Advil (ibuprofen)
Panadol (paracetamol)
Pain relief
Antihistamines
None of the above
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On the day of your tattoo
We strongly recommend eating a meal no more than 4 hours prior to your appointment. If you are booked for a Full Day session, we recommend planning ahead, by ordering or bringing food for a meal approximately halfway. You are welcome to bring any snacks and drinks that you would like to for your session.
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I understand & have/will follow the advice given to me
I understand & have chosen to NOT follow the advice given to me
Does your tattoo contain any spelling, or dates? If so, please provide a copy here:
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Please check all spelling, and dates, are correct. You will be asked to check this again during the stencilling process of your appointment.
Please select your chosen payment method. No EFTPOS provided.
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Cash (preferred)
Bank transfer
Gift voucher
Unsure
Other
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Consent & Waiver
By ticking the boxes below, you are agreeing that you understand, acknowledge, and what is stated below is true:
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I am atleast 18 years old & the ID I have provided is valid & my own.
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I am not currently under the influence of drugs or alcohol. I am of sound mind to give my full consent.
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I understand and acknowledge that tattoos are a permanent change to my body which involves puncturing my skin & inserting tattoo ink below the surface. no representation has been made to me as to the ability to later change or remove my tattoo.
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I am not pregnant to the best of my knowledge. I understand the risks of being tattooed & healing the tattoo during pregnancy, should I discover I am pregnant, and release my tattoo artist of any liability or responsibility.
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I have checked that the design, & spelling of any words, names, and or dates, to be included in my tattoo are correct. I understand that it is my responsibility to check the design provided to me, and the stencil once applied to my skin, does not have any errors, & contains the correct design, information and spelling. I understand I need to notify my artist prior to commencing tattooing of any changes that need to be made. I agree to assume responsibility for this, thereby releasing my tattoo artist of any liability or responsibility for errors in the design, incorrect information or spelling in my tattoo.
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I understand that the tattooing procedure exposes me to risks and I agree to assume responsibility for these risks, thereby releasing my tattoo artist of any liability or responsibility.
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I am aware that I may experience an allergic reaction to the dyes, pigments, ointments, materials, or processes used in my tattoo procedure. I acknowledge it is not reasonably possible to expect my tattoo artist to determine if I will have an allergic reaction. I am aware of the risks and assume responsibility for this risk, thereby releasing my tattoo artist of any liability or responsibility.
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I am aware that infection is always possible as a result of obtaining a tattoo. Particularly in the event that I do not take proper care of my tattoo. I acknowledge it is not reasonably possible to expect my tattoo artist to determine if I will or have developed an infection, and any advice given to me for the treatment of an infection does not replaced the advice given to me by a doctor. I am aware of the risks and assume responsibility for this risk, thereby releasing my tattoo artist of any liability or responsibility.
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I understand the risks involved with failure to follow the after-care instructions given to me. I understand that regardless of following the after care instructions there are still risks involved with healing my tattoo. I am aware of the risks and assume responsibility for this risk, thereby releasing my tattoo artist of any liability or responsibility.
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I acknowledged that I have been given the full opportunity to ask any and all questions which I might have about the obtaining of a tattoo and that all of my questions have been answered to my full satisfaction.
Signature
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