Booking
consent form for fresh pokes and touch-ups
Name
*
first name
last name
Pronouns
*
Email
*
example@example.com
Phone Number
*
-
area code
phone number
Address
*
street address
street address line 2
city
postal / zip code
Flash design
*
please enter flash code in description (see @offhandpokesflashes for flash designs), or enter "custom" for custom design requests
Placement
*
What date works for you?
*
/
Day
/
Month
Year
date
How did you hear about my services?
Please Select
Word of mouth
Social Media
QR code
Other
Do you have any accessibility requirements?
*
Yes
No
If yes, please fill out box below
Have you suffered from following medial conditions?
*
No
Heart disorders
Epilepsy or other forms of seizures
High blood pressure
Diabetes
Haemophilia or other blood disorders
Hepatitis
Autoimmune diseases
Allergies
Pregnant or breastfeeding
Skin conditions such as eczema and psoriasis
Allergic reactions to latex, anaesthesia or adhesive plasters
Other
Other (use this box to elaborate on any medical conditions ticked above)
Click 'next' for consent form
please take your time to read and answer all questions truthfully
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Consent Form
By checking this box, I agree that if I have any condition that might affect the healing of this tattoo, I will advise my tattooer. I am not pregnant or nursing. I am not under the influence of alcohol or drugs
*
I agree
By checking this box, I agree that I do not have medical or skin conditions such as but not limited to: acne, scarring (keloid) eczema, psoriasis, freckles, moles or sunburn in the area to be tattooed that may interfere with said tattoo. If I have any type of infection or rash anywhere on my body, I will advise my tattooer
*
I agree
By checking this box, I acknowledge it is not reasonably possible for the representatives and employees of this tattoo shop to determine whether I might have an allergic reaction to the pigments or processes used in my tattoo, and I agree to accept the risk that such a reaction is possible
*
I agree
By checking this box, I acknowledge that a tattoo is a permanent change to my appearance and that no representations have been made to me as to the ability to later change or remove my tattoo. To my knowledge, I do not have a physical, mental or medical impairment or disability which might affect my well being as a direct or indirect result of my decision to have a tattoo
*
I agree
By checking this box, I acknowledge that infection is always possible as a result of the obtaining of a tattoo, particularly in the event that I do not take proper care of my tattoo. I have received aftercare instructions, as required by the Cambridge Body Art Regulation, and I agree to follow them while my tattoo is healing. I agree that any touch-up work needed, due to my own negligence, will be done at my own expense
*
I agree
By checking this box, I agree that I will consult a health care practitioner at the first sign of infection or an allergic reaction and to report any diagnosed infection, allergic reaction, or adverse reaction resulting from the application of the tattoo to the artist and to the business 'Off Hand Pokes'
*
I agree
By checking this box, I release any and all rights to any photograph taken of me and/or my tattoo and give consent in advance to their reproduction in print or electronic form. (If you do not initial this provision, please remind your artist NOT to take any photographs!)
*
I agree
I do not agree
By checking this box, I acknowledge I am over the age of eighteen and that I have truthfully represented to my tattooer that the obtaining of a tattoo is by 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
*
I agree
By checking this box, I agree that I indemnify and hold 'Off Hand Pokes' harmless against any claims, expenses, damages, and liabilities
I agree
I acknowledge that Off Hand Pokes does not offer refunds
*
I agree
By signing this agreement, I represent and warrant that I have carefully read and fully understand this agreement and its final binding effect, that I have been advised to and afforded sufficient time and opportunity to review this agreement and had an opportunity to discuss and/or negotiate the terms of this agreement, that I am fully competent to manage my own business affairs and to enter into this agreement, and that I have signed this agreement knowingly, freely, and voluntarily
*
I agree
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