Have you been vaccinated against COVID-19? *

YES

NO

Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Gender

Male

Female

Way past those hang ups

Medical History *

Please check for YES if any listed below apply to you:

TB

Asthma

Eczema/Psoriasis

Gonorrhea

HIV

Hepatitis

Heart Conditions

Syphilis

Skin Conditions

Pregnant/Nursing

MRSA/Staph Infections

Diabetes

Blood Thinners

Fainting/Dizziness

Scarring/Keloiding

Epilepsy

Hemophilia

Latex Allergies

Antibiotic Allergies

Allergies to metals, soaps, cosmetics or alcohol

Do you use any medications that might affect the healing of the body art you wish to receive?

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

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

NONE OF THE ABOVE

INFORMED CONSENT TO RECEIVE BODY ART *

PLEASE READ AND CHECK THE BOXES WHEN YOU ARE CERTAIN YOU UNDERSTAND THE IMPLICATIONS OF SIGNING I, as the name listed above, confirm the following by initialing each applicable item: NOTICE*: Tattoo inks, dyes, and pigments that have not been approved by the federal Food and Drug Administration have health consequences that are unknown.

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

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. I understand the permanent nature of receiving body art and that removal can be expensive and may leave scars on the procedure site. I acknowledge that the information that I have provided in the medical questionnaire is complete and true to the best of my knowledge.

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

I understand the permanent nature of receiving body art

I understand the restrictions on physical activities during the healing process such as recreational water activities, gardening, contact with animals, and the duration of the restrictions.

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

I am aware that tattoo inks, dyes, and pigments used on the procedure site have not been approved by the federal Food and Drug Administration, and that the health consequences of using these products are unknown.

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 drainage from the procedure site.

I understand there is a possibility of getting an infection as a result of receiving body art particularly in the event that I do not take proper care of the procedure site.

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

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

I understand that there is a chance I might feel lightheaded or dizzy during or after being tattooed. If so I agree to immediately notify my tattooer.

BY CHECKING HERE YOU CONFIRM THAT YOU ARE THE PERSON REPRESENTINED IN THIS FORM *

I declare under penalty of perjury that the foregoing is true and correct.

I AM