Ink into Art Client Consent Form
Use this form to collect legally valid consent for body art procedures, including medical screening, required acknowledgments, aftercare confirmation, and all required signatures and dates.
Client Information
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Email
*
example@example.com
Instagram
*
Emergency Contact Name
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Consent and Acknowledgments
I confirm I am 18 years of age or older and I understand that body art services may require legal identification
*
Yes
If the procedure is body piercing and I am under 18, I confirm a parent or legal guardian is present and consents
*
Yes
I confirm I am not under the influence of alcohol or drugs and I am consenting voluntarily
*
Yes
I understand the procedure is permanent and may involve scarring, and removal may require additional expense
*
Yes
I confirm the placement and design are correct according to my specifications
*
Yes
I confirm my questions have been answered and I have received aftercare instructions
*
Yes
I understand I must follow activity restrictions for the recommended period of time
*
Yes
I understand the infection risks and symptoms to watch for, including redness, swelling, tenderness, red streaks toward the heart, elevated body temperature, and purulent drainage
*
Yes
I understand I may feel lightheaded or dizzy during or after tattooing and I will notify the artist immediately if this occurs
*
Yes
Procedure Details and Medical Screening
Artist Name
*
Type of Body Art Being Performed
*
Tattoo
Piercing
Procedure placement
*
Description of Procedure
*
Medical History Conditions
TB
Asthma
Antibiotic Allergies
Hemophilia/Bleeding Disorders
HIV
Hepatitis
Diabetes
Heart Condition
Seizure Disorder
Other
Are you prescribed antibiotics prior to dental or surgical procedures?
Yes
No
Do you have any additional allergies to metals, soaps, cosmetics or alcohol?
Yes
No
Do you use any medications that might affect the healing of the body art?
Yes
No
Do you have a history of herpes at the procedure site or any other skin conditions?
Yes
No
What medications do you currently use? Other medical conditions?
Client Signature and Identification
Printed Client Name
*
Signature of Client
*
Date
*
-
Month
-
Day
Year
Date
Type of Identification Provided
*
Driver’s License
Passport
Birth Certificate
State issued ID
Upload ID
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