Over the Moon Tattoo Client Consent Form

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Client Consent Form

Don't forget to have your government issued photo ID ready for your appointment, it's required to get tattooed!

Plymouth Public Health Department

Address: 26 Court St, Plymouth, MA 02360

Phone Number: 508-747-1620 (ext 10118)

Company Contact Information

Company Name: Over the Moon Tattoo Studio LLC

Address: Image Studios 360, Suite 109, 55 Commerce Way, Plymouth, MA 02360

Phone Number: 774-699-1574

Email: otmoontattoo@gmail.com

All tattoo clients must sign and receive a copy of this form prior to any tattoo procedure. Keep original form on the premises.

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I understand that all of the information disclosed in this form will be kept confidential and that a copy of this consent form will be provided to me.* This field is required.

I understand.

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Today's Date* This field is required.Please select today's date

Date

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Body Art Practitioner Performing the Tattoo* This field is required.Who are you getting tattooed by today?

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I'm aware that the body art practitioner who is performing my service today is a:* This field is required.

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Participant's Name & Contact Info* This field is required.

First Name

Last Name

Phone Number

Email

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Participant's Address* This field is required.

Street Address

Street Address Line 2

City

State

Zip Code

Country

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Participant's Date of Birth* This field is required.

Date

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Photo of the front and back of the participant's state issued driver's license / state ID card / passport* This field is required.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

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DISCLOSURE

By signing this form, I acknowledge that I have read and understand the following:

- As with any invasive procedure, tattooing may involve possible health risks. These risks may include the following:

Pain, bleeding, swelling
Scarring, hypertrophic scarring, and keloid formation
Possible adverse or allergic reaction to ink/dye pigment
Decreased ability of physician to locate skin melanoma in tattoo area
Possible nerve damage
Fever
Tetanus
Infection - local or systemic

Additionally, I understand that infection is always a possible result of obtaining a tattoo, particularly in the event that I do not take care of my tattoo.

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Do you have, to your knowledge, any of the following health conditions?* This field is required.Please select all that apply.

Diabetes

Hemophilia

Skin diseases, lesions, sensitivities to soaps, disinfectants, etc.

History of allergies or adverse reactions to pigments, dyes, or other sensitivities

History of epilepsy, seizures, fainting, or narcolepsy

Use of medications such as anticoagulants which thin the blood and/or interfere with blood clotting

Hepatitis or HIV infection

None of the above

Other

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I understand having any of the aforementioned conditions may increase health risks associated with receiving a tattoo.* This field is required.

I understand.

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Are you currently taking any medications? If so, which ones?* This field is required.

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By initialing below, I confirm that I will advise my tattoo artist if I have any condition that might affect the healing of this tattoo. I do not have a condition that prevents me from getting tattooed.* This field is required.

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By initialing below, I confirm that I am not pregnant, do not suspect that I may be pregnant, and am not nursing.* This field is required.

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By initialing below, I confirm that I am not under the influence of alcohol and/or drugs.* This field is required.

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By initialing below, I confirm that I am over the age of 18 and that I have truthfully represented to my tattoo artist that the obtaining of a tattoo is my choice alone. I consent to the application of the tattoo and to any actions or conduct of the representatives and employees of the tattoo shop reasonably necessary to perform the tattoo procedure.* This field is required.

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I understand that tattoos should be considered permanent. Removal of a tattoo may require surgery or other medical procedures which in some cases, may result in scarring or additional scarring of the skin. Tattoos may cause permanent discoloration.* This field is required.

I understand.

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I understand that the inks, or dyes, used for tattoos are color additives. Currently, no color additives have been approved by the FDA for tattoos. * This field is required.

I understand.

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By initialing below, I confirm that I understand that over time, tattoos change and fade - this includes thickening of lines and changing of the color of the inks/dyes/pigments in the skin. I also understand that if I have skin treatments, laser hair removal, surgery or other skin altering procedures, it may result in adverse changes to my tattoo.* This field is required.

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I understand that I should contact a health care provider if I experience any of the following symptoms after receiving a tattoo: unexpected redness/tenderness/swelling at the site of the tattoo, rash, unexpected drainage from the site of the tattoo, or fever within 24 hours of getting tattooed.* This field is required.

I understand.

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I understand that the procedure for filing a complaint is as follows: If there is any sign of injury, infection, complication or disease as a result of a tattoo procedure, first contact a healthcare provider for medical evaluation. Then, notify this establishment and the Plymouth Public Health Department at 26 Court St, Plymouth, MA 02360. They can be contacted at 508-747-1620 (ext 10118).* This field is required.

I understand.

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Additional Health Concerns / Disclosed Conditions / Medications Currently Taking (if any are applicable)

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By initialing below, I confirm that I have been given the full opportunity to ask any and all questions which I might have about the tattoo procedure and that all of my questions have been answered to my full satisfaction.* This field is required.

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By initialing below, I confirm that I have received tattoo aftercare instructions provided by Over the Moon Tattoo Studio and will follow these instructions to the best of my availability. * This field is required.Aftercare instructions can also be found at www.overthemoontattoostudio.com

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I release all rights to any photographs taken of me and the tattoo I have received at Over the Moon Tattoo Studio and give consent in advance to their reproduction in print or electronic form (including, but not limited to, in magazines, on instagram, for convention banners, etc)* This field is required.

YES, I consentNO, I do not consent

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Electronic Signature Consent* This field is required.

By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such a copy, and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.

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Participant's Signature* This field is required.

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