Date *

MM

DD

YYYY

Name *

First Name

Last Name

Phone

(###)

###

####

Are you currently under the influence of drugs or alcohol? *

Y

N

Are you pregnant or nursing? *

Y

N

Do you have a history of fainting or dizziness? *

Y

N

Have you eaten in the last 4 hours? *

Y

N

Do you have any allergies (e.g., latex, ink, medications)? *

Y

N

Do you have any medical conditions (e.g., diabetes, heart condition, skin disorders)? *

Y

N

Are you currently taking any medication? *

Y

N

Do you have any other health issues or concerns we should be aware of? *

Y

N

Confirmation of the following:

I have provided accurate information about my medical history. I understand the risks associated with getting a tattoo, including but not limited to infection, allergic reactions, and scarring. I agree to follow the aftercare instructions provided by the tattoo artist. I understand that the tattoo artist will not be held liable for any problems arising from my failure to follow the aftercare instructions. I have reviewed and approved the design, placement, and spelling (if applicable) of the tattoo. I release the tattoo artist and studio from all liability related to the tattoo process and any potential complications. I consent to photographs of the tattoo for the artist’s portfolio and promotional purposes.

Yes

No