Tattoo Consent Form
Take a picture of your ID
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Name
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First Name
Last Name
Email
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example@example.com
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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Area Code
Phone Number
Date Of Birth
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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Read and Check All The Boxes
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I am eighteen (18) years of age or older, have no guardian or committee appointed for me by any court anywhere and am competent to give my consent.
I am not pregnant
I am not breastfeeding
I am not bulimic or anorexic
I am not diabetic.
I do not have epilepsy
I am free of Communicable Diseases.
I do not wish to have a patch test.
I have eaten with in the last 2 hours.
I am not taking blood thinners in the last 24 hours.
I am not on Antibiotics.
I am not prone to dizziness or fainting.
I do not suffer from seizures.
I do not have hepatitis a, b or c.
I do not have HIV/AIDS.
I do not have high or low blood pressure.
I am not prone to heavy bleeding.
I am have not had an adverse reaction to plasters.
I have never had an adverse reaction to a tattoo
I have not consumed alcohol or recreational drugs in the last 24 hours.
I have received verbal instructions advising me of the proper care of my tattoo and I recognise the necessity for following these instructions.
I understand that i am responsible for the care of my tattoo for I might have an allergic reaction to inks, aftercare ointment or the processes used in the tattoo; and I voluntarily assume and accept all risks that such reactions are possible.
I understand that a tattoo is a permanent change to my body and appearance and no representation has been made that once made, any tattoo can be altered or removed
My tattoo is by my choice alone, and I have not been influenced in anyway by Ross Whaley to obtain a tattoo or any other third party.
I consent to the application of my tattoo, and procedures necessary to perform the tattoo.
I understand that there are risks involved in the application of a tattoo and there are NO REFUNDS once a tattoo has been paid.
I have checked the spelling. dates and stencilling and confirm they are correct.
I covenant and declare that I am not intoxicated or under the influence of drugs or alcohol.
I covenant that Ross Whaley may refuse to perform my tattoo at Ross Whaley's sole discretion.
I do not have any medical problems which in any way affect or might affect my tattoo. if so i will specify below.
I understand my tattoo may scab, i will not pick, irritate, submerge or cause harm purposely to my tattoo during the healing stage or there after.
I am have no known allergic reactions, if so i will specify below
Enter any medical problems which in any way affect or might affect my tattoo
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Disclosure Statement
As with any invasive procedure, tattooing can involve possible risks.
Please tick all so you are aware of these risks
Pain, bleeding, swelling, trauma, infection, scarring and nerve damage
Infection is possible as a result of a tattoo, particularly in the event that I fail to take proper care of my tattoo.
Blood poisoning (septicaemia) or allergic reaction.
Inks contain metals such as nickel and red inks may cause reactions.
Tattooing is not easily removable in some cases will cause permanent decolorisation. Tattoos change and fade with time.
Tattoos on average take 2/3 week to appear healed and up to 8 weeks to fully heal.
Blood donations cannot be made for 6 months of having a tattoo.
If i subsequently find spellings / dates to be incorrect or do not follow the aftercare guidance I take full accountability for the healing of my tattoo and will hold no resource against my appointed artist (Ross Whaley) at Roscoe Ink once the tattoo has been completed.
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Signature
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