Name
*
First Name
Last Name
E-mail
*
Phone Number
*
Age
*
Date of Birth
*
-
Month
-
Day
Year
Date
Upload a photo ID
*
Pre-Procedure Questionnaire
Are you under the influence of drugs or alcohol?
*
Yes
No
FEMALE ONLY: Pregnancy or Nursing?
Yes
No
Do you have a communicable disease?
*
Yes
No
Skin conditions (e.g. Rashes, eczema, infection, psoriasis, freckles, etc.)
*
If yes, please identify the condition.
Medical History (e.g. DIabetes, Cardiovascular Disease, Epilepsy, Blood-related disease etc.)
*
If yes, please identify the condition.
Terms & Conditions
*
I understand that this procedure is a permanent change to my skin and body.
I allow my tattoo to be photographed and be used for Lavan Wright's [Tattoo artist] portfolio.
I acknowledge that the Tattoo artist does not offer refund.
I agree that the studio does not have a way of identifying if I am allergic to the elements or ingredients that will be used for my tattoo.
I understand that I need to take care of the tattoo by following the instructions given to me by the Tattoo artist.
I understand that I might get an infection if I don't follow the instructions given to me in regards of taking full care of my tattoo.
I indemnify and hold harmless the Tattoo artist against any claims, expenses, damages, and liabilities.
I confirm that the information I provided in this document is accurate and true.
Client Signature
*
Signed Date
*
-
Month
-
Day
Year
Date
Submit
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