JBTattoo Consent Form

JBeanTattoo Consent Form

Please review and complete this form to give your consent for the tattoo procedure.
Name of client

First NameLast Name
Date of Birth

MonthDayYear
Date
Age
State License ID #
Picture of State ID

Cancelof
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Site of procedure (& design if applicable)
FOR CLIENTS INFORMATION

*known (potential) risks associated with tattooing
- Scarring
- Blood poisoning (Septicaemia)
- Localised Infection
- Allergic reaction to pigment
- Localised swelling around the site
Individual Consent

I declare that I give my full consent to the tattooing being carried out by the aforementioned practitioner. I confirm that potential complications, e.g. infection and swelling, for the procedure undertaken, and aftercare instructions hace been explained to me. A written aftercare advice sheet containing more detailed information has been given to me and I agree that it is my responsibility to read this and follow the instructions on it, until the site has healed.

I confirm that the above information provided by me for this consent form is correct to the best of my knowledge, that I am over the age of the consent for this procedure (i.e 18 years old for tattoos) and that I am not currently under the influence of alchohol of drugs.
Signature of client:
Date

MonthDayYear
Date
Artist Signature
The nature and method of the proposed tattoo procedure has been explained to me as having the usual risks inherent in the procedure and the possibilty of complications during and following its performance. I understand that thtere may be a certain amount of discomfort or pain associated with the procedure and that other possible adverse side effects may include: minor and temporary bleeding, bruising, redness or other discoloration and/or swelling. Fading or loss of pigment may occure. Secondary infection in the area of the procedure is rare if properly cared for, but may occasionally occur.

By signing below, I specifically acknowledge that I have been advised of the facts and matters set below, and I agree as follows:
Date

MonthDayYear
Date
Signature* I have informed the practitioner of any and all of my known allergies. I acknowledge that it is not always reasonably possible to determine in advance whether I might have an allergic reaction to any of the pigments, dyes, topical preparations, or processes used in the procedure; and I agree to accept the risk that such reaction is possible.
Signature* I acknowledge that complications as a result of tattoo procedures may occur, particularly in the event that the post-procedural instructions are not followed, and accept full responsibility for such complications.
Signature* I realize that my body is unique and neither Jocelyn Mahayag/Pensacola PMU nor employees or contractors can predict how my skin may react as a result of the procedure.
Signature I have previously had tattooing performed by someone other than Jocelyn Mahayag on the same area that I am asking Jocelyn Mahayag to work on today
Signature IF YES, I understand that correcting or touching up tattoos that was performed by others involves additional risks because of the existence of permanent pigments of unknown composition, brand, colour, age, shape and other factors over which Jocelyn Mahayag/Pensacola PMU has no control. I understand that additional appointments after the initial and follow-up appointments may be required and will be billled at Jocelyn Mahayag’s standard rates. I understand that Jocelyn Mahayag/Pensacola PMU can not predict the results in advance and cannot guarantee and has not represented that the results will be as I desire. I understand and fully accept the risk associated with this procedure and hold Jocelyn Mahayag and Pensacola PMU harmless from same.
Signature* I acknowledge that the procedure may result in a long-lasting (many years) change to my appearance and that no representations have been made to me as to the ability to later change or remove the results.
Signature* I understand that future skin altering procedures such as laser treatments, plastic surgery, implants and/or injections may alter and degrade my tattoo, and that I must inform any future service provider that I have had permanent tattoos applied. I understand and accept that such changes are not the fault of Jocelyn Mahayag/Pensacola PMU or its employees or contractors. I further understand that such changes or degradation in my appearance may not be correctable through further tattoo procedures.
Signature* I consent to the admittance of authorized observers to the procedure(s) for the purpose of education or assistance.
Signature* I acknowledge that obtaining the tattoo is my choose alone, and I consent to the procedure and to it’s attendant risks, and to any actions or conduct of Jocelyn Mahayag and it’s employees and contractors reasonably necessary to perform the procedure.
Signature* I understand that I will have the opportunity to approve the design and the colour of the tattoo to be applied, and I accept responsibility for the same.
Signature* I consent to any relevant photographs being taken before, during and after the procedure, to document the results of the procedure and/or for educational purposes for use of Jocelyn Mahayag/Pensacola PMU.
Signature* I consent to Jocelyn Mahayag using “before & after” photos of me for marketing purposes to display its capabilities and results.
Signature* I have been given the full opportunity to ask any and all questions which I have, about obtaining Tattoo procedures from a specialist-Jocelyn Mahayag/Pensacola PMU and that all of my questions have been answered to my full and total satisfaction.
If you have previously had tattoos performed by Jocelyn Mahayag has your medical history changed since you last filled out J.BTattoo consent form?
If YES, please specify,
I have read and understand the contents of each statement above. I acknowledge that this is a contract and that I have recieved no warranties or guarantees with respect to the benefits to be realized from, or consequences of, the aforementioned procedure(s). I further acknowledge that at the time of signing this consent I am of sound mind and capable of making independent discussions for myself.
First Name Last Name ( Please print Legibly) Date
Client Signature Date
Practitioner Statement:

I have personally reviewed the above information with my client.
Practitioner Signature Date
By signing below, I acknowledge, understand and agree that:
- Jocelyn Mahayag and the staff at Pensacola PMU do not practice medicine, do not accept health insurance, and have made no representation to the contrary.
- The information provided on this form is accurate and complete to the best of my knowledge, and that Jocelyn Mahayag, it's staff and students are not responsible for complications or problems arising from any incorrect or omitted information;
- Some individuals will have complications related to tattoos. These complications are usually mild and last only a few days. However, extreme complications are always a possibility. I accept these risks and agree to hold Jocelyn Mahayag and its employees, contractors and students harmless for same;
- Jocelyn Mahayag and the staff at Pensacola PMU will use information provided above to assess suitability for the proposed tattoo service.
- I am completely satisfied with my shape, color and overall work when I leave.
Client Signature Date
I HAVE READ AND UNDERSTAND THE AFTERCARE INSTRUCTIONS. I ACCEPT THAT FAILURE TO FOLLOW THE POST-PROCEDURE INSTRUCTIONS MAY RESULT IN A LOSS OR DISCOLORATION OF PIGMENT RESULTING IN A NEED FOR MORE FREQUENT TOUCHUPS. NO GUARANTEES, NO REFUNDS.
First Name Last Name ( Please print Legibly) Date
Client Signature Date
Should be Empty:

JBeanTattoo Consent Form

FOR CLIENTS INFORMATION

Practitioner Statement: