Client Information and Health Form
Please read and complete all questions below.
Name: *
Date of Birth *
MM
/
DD
/
YYYY
Drivers License or State ID: *
Phone Number *
Address:
Email: *
Are you currently under the care of a physician? *
If yes, why? Please put physician name and phone number.
Do you take antibiotics when going to the dentist? *
If yes, why?
Do you suffer from the following: *
Required
Are you pregnant or nursing? *
Are you taking medication which thins the blood? *
Are you taking other medications including anti-depression or mood altering drugs? *
Are you on medication for a thyroid issue? Medications that are used to treat thyroid issues can have an affect on the healed result. *
Please list any other medications you take on a regular basis: *
I acknowledge by signing this agreement that I have been given the full opportunity to ask any and all questions which I might have about the obtaining of a tattoo and that all of my questions have been answered to my full satisfaction. I specifically acknowledge that I have been advised of the facts and matters set forth below and I agree as follows: *
Required
I certify that I have read everything above and by typing my name below it serves as my signature: *
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