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- Date of Birth*
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Format: (000) 000-0000.
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Format: (000) 000-0000.
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- Are you pregnant or nursing?*
- Do you have diabetes?*
- Do you have a heart condition, a pacemaker, or high blood pressure?*
- Do you have a bleeding disorder, or take blood thinners (including aspirin in the last 24 hours)?*
- Do you have epilepsy, or a history of seizures or fainting?*
- Do you have a condition, or take medication, that weakens your immune system?*
- Have you taken isotretinoin (Accutane) in the last 12 months?*
- Are you allergic to latex, metals, inks, antiseptics, or numbing creams?*
- Is there a rash, sunburn, mole, eczema, or psoriasis on or near the tattoo area?*
- Do you tend to form keloids or raised scars?*
- Have you had alcohol or recreational drugs in the last 24 hours?*
- Have you eaten a meal in the last 4 hours?*
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- Date*
- Optional permissions
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- Should be Empty: