Name *

First Name

Last Name

Birth Date *

MM

DD

YYYY

Phone *

(###)

###

####

Address *

Must match licence

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Have you consumed Drugs or Alcohol in the last 24 hours? *

Yes

No

Are you pregnant or nursing? *

Yes

No

Do you have a infectious disease? *

Yes

No

Do you have a skin condition? *

eg, rash, eczema, infection, freckles, psoriasis etc.

Yes

No

Do you have any medical history? *

eg, diabetes, epilepsy, blood related disease, cardiovascular disease etc.

Yes

No

Acknowledgement and Waiver *

I understand that tattooing is a permanent procedure to my skin and body

I allow my tattoo to be photographed and posted online

I acknowledge that the tattoo shop does not offer refunds

I agree that the studio does not have a way of identifying if I'm 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 do not follow the instructions given to me in regards to taking good 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 true and accurate

Todays Date *

MM

DD

YYYY