Name *

First Name

Last Name

Phone *

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Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Client's agreement to tattoo design and placement *

All design elements and placement have been discussed prior to appointment date. If I, the client, adds to or changes the design/idea OR the placement the day of the appointment I understand and will pay the $250 fee for last minute changes.

I understand & agree

CHECK ALL THAT APPLY TO YOU. By checking that which applies you are aware of and understand the risks of this procedure. By law you are obligated to declare any medical conditions that may affect this procedure.

I need parent consent because I am not 18+

I have consumed alcohol or drugs within the last 8 hours

I have a heart condition

I am diabetic

I have or currently am undergoing medical treatment (i.e. Chemotherapy)

I suffer from seizure causing conditions

I have reactions to pigments / dyes

I have high blood pressure

I am allergic to the Penicillin family of drugs

I have a condition that affects my immune system

I have a blood clotting disorder / I am taking blood thinning medication

I am pregnant or nursing

I am prone to dizziness / fainting

I have Hepatitis A, B, C, D or E

I have HIV / AIDS

I have allergies (Please list them below)

Client Agreement - Skin and Allergies *

I understand that skin conditions such as Eczema, Psoriasis, and other medical conditions leaves me more prone to skin infections. I understand that the tattoo artist does not have a way of identifying if I am allergic to the elements that will be used for my tattoo.

I agree and give my consent

Client Consent to procedure, after-care and refund terms & conditions *

I understand that this procedure is a permanent change to my body. I acknowledge that the tattoo shop does not give refunds. I consent to any actions or conduct of the representative necessary to perform the procedure. I understand that I should follow the after-care instructions provided by the artist, and if I decided not to, the artist is not held liable for how the tattoo heals. I understand my tattoo is subject to infection if I do not follow the instructions given to me by the tattoo artist.

I agree and give my consent

Client Agreement to photo / video content *

I agree to allow the tattoo shop to take photos / video content and grant permission for these to be used by the tattoo shop / artist to promote the artwork on all social media platforms as well as any other promotional item (i.e. flyers, posters, websites, etc.)

I agree and give my consent

Date *

MM

DD

YYYY