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Client Consent Form

Client Information

Date of Birth
Month
Day
Year

Please upload a clear photo of the front and back of your ID.

RISK NOTIFICATION:

Body art can cause swelling, bruising, discomfort, bleeding, and pain.

Body art can cause allergic reactions.

Body art can cause irreversible changes to the human body.

Body art has a risk of infection.

INFORMED CONSENT AND RELEASE FORM

Please check the box next to each statement to confirm that you truthfully agree with it as you read through.

CLIENT EVALUATION

Please answer all questions truthfully and to the best of your ability. These questions pertain to factors that may impact the healing process of your tattoo and your suitability for receiving a tattoo.

Consult a medical care provider prior to the procedure if you have any concerns about any of the questions below.

Have you consumed alcohol within the last 48 hours?
Yes
No
Are you under the influence of drugs or alcohol?
Yes
No
Have you ingested anticoagulants, anti platelet drugs, or NSAIDS (aspirin, ibuprofen, etc.) in the last 24 hours?
Yes
No
Have you ingested any medication that can inhibit the ability to heal a skin wound?
Yes
No
Do you have any allergies or adverse reactions to dyes, pigments, latex, adhesive, iodine, or other such products?
Yes
No
Do you have any allergy or sensitivity to gluten?
Yes
No
Do you have hemophilia, epilepsy, a history or seizure, fainting, narcolepsy, or other conditions that could interfere with the body art procedure?
Yes
No
Do you have a history of any diseases, including skin diseases, that might inhibit the healing of the body art procedure?
Yes
No
Do you have any communicable diseases that could be transferred to another person during the procedure?
Yes
No
Do you have diabetes, high blood pressure, heart condition, heart disease, or any other condition that could interfere with the body art procedure?
Yes
No
Are you or have you been pregnant within the last 3 months?
Yes
No
Have you consumed excessive caffeine in the last 24 hours?
Yes
No
Have you consumed alcohol within the last 48 hours?
Yes
No

By signing below, I confirm that I have read and understand this consent form, and that all information I have provided is accurate and truthful. I also acknowledge that I have reviewed and understand all shop policies, and I agree to abide by them. I hereby give my consent to receive a tattoo.

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