Tattoo and Piercing Consent Form
Please complete this form to provide your consent and necessary health information prior to your tattoo or piercing procedure.
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Emergency Contact Name
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Do you have any allergies?
*
No
Yes (please specify)
If yes, please list your allergies
Do you have any medical conditions (e.g., diabetes, heart conditions, skin disorders)?
*
No
Yes (please specify)
If yes, please describe your medical conditions
Are you currently pregnant or breastfeeding?
*
No
Yes
Have you consumed alcohol or drugs in the past 24 hours?
*
No
Yes
Procedure Type
*
Tattoo
Piercing
Location on Body (please specify)
*
Signature (Please sign below to provide your consent)
*
Submit Consent
Submit Consent
Should be Empty: