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Tattoo Consent / Waiver
First name and Last Name
*
Date of birth:
*
Month
Day
Year
Phone
Email
*
Emergency Contact - Name & Phone Number:
Tattoo Information (Placement, brief description):
*
Are you currently pregnant or breastfeeding?
*
Yes
No
Does not apply
Do you currently have any skin condition, irritation, rash, infection, open wound, sunburn, or other skin concern in or near the area being tattooed?
*
Yes
No
If yes, please explain:
Do you have any of the following? Check all that apply:
*
Diabetes
Bleeding or clotting disorder
Heart condition
Seizure disorder / epilepsy
History of keloids or abnormal scarring
Skin condition such as eczema, psoriasis, or dermatitis
Allergies or previous reactions to tattoo ink, pigments, latex, adhesives, or topical products
Currently taking blood-thinning medication or medication that may affect healing
Other medical condition that may affect the tattoo procedure or healing
Immune system condition or immunosuppression
None of the above
Other : _____________________
Consent & Acknowledgments
*
I confirm that I am at least 18 years old and have provided valid government-issued photo identification.
I understand that tattooing involves permanently depositing pigment into the skin and that results may vary depending on skin type, placement, healing, aftercare, and other individual factors.
I understand that tattooing involves risks, including but not limited to infection, allergic reaction, irritation, scarring, pigment changes, and other complications.
I confirm that I have disclosed any health information that I believe could reasonably affect my tattoo procedure or healing.
I voluntarily consent to receiving the tattoo described above.
Signature
*
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