BloodViolet Tattoo Consent
- Client Intake - Informed Consent - Procedure Acknowledgement -
Full Legal Name
*
First Name
Last Name
Preferred Pronouns
She/her
He/him
They/them
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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.
Please upload a picture of your government issued photo ID:
*
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Date of procedure
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Tattoo Artist
*
Please Select
Sylvie Kates
Robert Obrochta
Description of tattoo:
*
Tattoo placement:
*
Are you currently taking any anticoagulants, blood thinners, or any other medication that may affect blood clotting or healing?
*
Yes
No
If so, please list any medications and give a brief explanation:
Do you have diabetes
*
Yes
No
Do you have hemophilia or any other bleeding/clotting disorder?
*
Yes
No
Do you currently have any skin diseases or lesions?
*
Yes
No
Please list any known allergies to latex, pigments, soaps, or disinfectants. If none, skip this question.
Do you have a history of dizziness, fainting, or lightheadedness?
*
Yes
No
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*
I understand that tattooing is permanent and may involve pain, bleeding, swelling, irritation, infection, allergic reactions, scarring, pigment changes, or other healing complications.
*
I have disclosed any relevant health information, had the opportunity to ask any questions, and voluntarily consent to the tattoo procedure.
*
I confirm that I am not currently impaired by alcohol, recreational drugs, or any other substance that prevents me from knowingly consenting to this procedure.
*
I have reviewed and approved the final design, size, and placement of my tattoo - including any spelling, dates, numbers, or symbols and I understand changes may not be possible once tattooing begins.
*
I have received written and verbal aftercare instructions and understand how to take care of my tattoo, what to expect during healing, possible complications, and when to seek medical attention for signs of infection or allergic reactions. I agree to follow the aftercare instructions provided.
I allow BloodViolet Tattoo to photograph and/or record my tattoo for social media, portfolios, advertising, or other promotional purposes.
I certify that I have filled out this form truthfully and to the best of my knowledge. I confirm that I understand the information contained in this form, and I have had the opportunity to ask questions. With this information, I voluntarily consent to the tattoo procedure.
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ARTIST USE ONLY
Artist Name
Please Select
Sylvie Kates
Robert Obrochta
Lot numbers + expiration dates of supplies used for procedure
Should be Empty: