Consent Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Consent Form

Name (first and last) *

Date of Birth *

YYYY

Address *

Phone number *

Email *

Emergency Contact *

Type of identification provided *

Medical history *

Diabetes

Hemophilia

Skin disease

Skin lesions

Skin sensitivity to soap or disinfectant

Seizures

Fainting

Narcolepsy

Required

Any other health information *

Last time you ate

Time

Do you have additional allergies such as to metals, soaps, cosmetics, or alcohol? *

Yes

Do you have any condition that requires you to take medications such as anticoagulants that thin the blood or interfere with blood clotting?

Yes

Have you ever been prescribed antibiotics prior to dental or surgical procedures?

Yes

Do you have any other medical or skin conditions that might affect the outcome of this procedure?

Yes

Do you have a cardiac valve disease *

Yes

I confirm the following by checking each applicable item below

I understand that a tattoo is considered permanent and may only be removed with a surgical procedure

True

The body art described or shown on this form is correctly placed to my specifications. If applicable, I have also confirmed all spelling and grammar necessary in the procedure

True

All questions about the body art procedure have been answered to my satisfaction, and I have been given written aftercare instructions for the procedure l am about to receive

True

I understand that any medical information obtained will be subject to the federal Health Insurance Portability and Accountability Act of 1996 (HIPPA)

True

I understand the restrictions associated with this body art procedure as explained by the technician

True

I understand that any effective removal of a tattoo or body piercing may leave scarring

True

I am the person on the legal ID presented as proof that 1 am at least 18 years of age

True

I am not under the influence of alcohol or drugs and that I am voluntarily submitting myself to receive body art without duress or coercion

True

I acknowledge the information i provided in the medical questionnaire is complete and true to the best of my knowledge

True

I am aware of the signs and symptoms of infection, including but not limited to, redness, swelling, tenderness of the procedure site, red streaks going from the procedure site towards the heart, elevated body temperature, or purulent draining from the procedure site

True

I understand there is a possibility of getting an infection as a result of receiving body art

True

I will seek professional medical attention if signs and symptoms of infection occurs

True

I agree to follow all instructions concerning the care of my body art procedure and that any touch-ups needed due to my own negligence will be done at my own expense

True

I understand that there is a chance that I might feel lightheaded or dizzy during or after being tattooed

True

I agree to immediately notify the artist in the event I feel lightheaded, dizzy, and/or faint before, during or after the procedure

True

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Forms