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MEDICAL HISTORY and TATTOO CONSENT AND RELEASE FORM
Please check any conditions listed below that apply to you.
| Diabetes | HIV / AIDS | Heart Condition | Faint or Dizzy | ||||
| Epilepsy | Hemophilia | Eczema/Psoriasis | Infections | ||||
| T.B. | Scarring/Keloiding | Herpes | Asthma | ||||
| Hepatitis | Pregnant | Nursing | Blood Thinners |
FILL OUT COMPLETELY (N/A IS NOT AN ANSWER):
How long has it been since you last ate? __________________________________________________________
Do you have any allergies? ____________________________________________________________________
List all medications you are currently taking. _______________________________________________________________
Are there any other known MEDICAL CONDITIONS or CONTAGIOUS DISEASES that may
affect your TATTOO procedure? _________________________________________________________________________________
|
PHYSICIAN’S INFORMATION (IF NONE LIST CLOSEST HOSPITAL): Physician’s Name: _____________________________________ Ph # _______________________________ Address___________________________________________ City__________________ |
- I hereby certify that to the best of my knowledge this information is correct.
- All Questions have been answered to my satisfaction.
- I agree the said TATTOO is correctly drawn to my specifications.
- I understand that the said TATTOO is PERMANENT.
- This is to certify that I am at LEAST 18 YEARS OF AGE.
- I am not under the influence of ALCOHOL OR DRUGS.
- I understand there is a possibility of an allergic reaction.
- I understand there is a possibility of an infection.
- I agree to allow for ARTIST INTERPRETATION.
- I agree to follow all instructions concerning the care of my TATTOO.
- I understand that there is a chance I might feel lightheaded, dizzy and/or
faint due to my decision to receive a TATTOO. - I agree to IMMEDIATELY notify the artist in the event I feel lightheaded,
dizzy and/or faint before, during or after the procedure. Failure to do so
releases _____________________________ and ARTISTS of all responsibility. - I hereby release _______________________ and ARTISTS of all responsibility for
the said TATTOO. - NO REFUNDS.
CUSTOMER’S INFORMATION (FILL OUT COMPLETELY):
| Customer Printed Name: ________________________________________
Customer Signature / Parental Signature____________________________ Date__________ Address______________________________________ City______________ State____ Driver’s License #______________________________ DOB__________________ Race _______________ Sex _______________ Design__________________________ Placement________________________ Artist______________ Artist Signature ______________________ Emergency Contact ______________________________________________ Ph# _________________ Address______________________________________ City______________ State____ |
If under 18, child and parent(s) signatures need to be done in presence
of a notary. All blanks must be filled in. Parent(s) must be present and proper
identification must be presented prior to service.
I give my permission for my child to receive the said TATTOO.
Parental Signature_____________________________________ Date______ DL#________________________
Minor Signature______________________________________ Date______ DL#________________________
Notary Statement
Sworn and Scribed before me on this ______ Day of _________________ 200___
Notary____________________________________ Seal:
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