Name *

First Name

Last Name

Phone *

(###)

###

####

Birth Date

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Are you under the influence of any drugs or alcohol?

Yes

No

Do you have any communicable diseases?

(e.g. STI’s, HIV, hepatitis, etc.)

Yes

No

Are you pregnant or nursing?

Yes

No

Do you have any skin conditions?

(e.g. eczema, psoriasis, rashes, etc.)

Yes

No

Are you on any blood-thinning medication?

Yes

No

I understand that this procedure is a permanent change to my skin and body.

Yes

No

I allow my tattoo to be photographed and shared on social media/used for portfolio purposes.

Yes

No

I acknowledge that a refund is not applicable for my tattoo.

Yes

No

I acknowledge that my artist does not have any way of identifying if I am allergic to the elements or ingredients that will be used for my tattoo.

Yes

No

I understand that I need to take care of the tattoo by following the aftercare instructions and that failing to do so may lead to complications or infection.

Yes

No

I indemnify and hold harmless the artist against any claims, damages, expenses and liabilities.

Yes

No

Date Signed

MM

DD

YYYY