Tattoo Waiver, Release, and Consent Form
Please review and complete the form to give your consent for the tattoo procedure.
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Do you have any allergies, medical conditions, or are you currently taking any medications?
*
Have you eaten in the last 4 hours?
*
Yes
No
Tattoo Placement (Body Location)
*
Tattoo Description
*
Signature (Please sign below to confirm your consent and agreement to the terms above.)
*
Date Signed
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Submit
Should be Empty: