Consent Form

CLIENT INFO

Name *

Name

First

Last

Date of Birth *

MM/DD/YYYY

Address

City

State/Province

Zip/Postal

Phone

Email *

Emergency Contact Name *

Emergency Contact Phone *

Type of Identification Provided

Driver's License

Passport

Military ID

Tribal ID Card

Permanent Resident Card (Green Card)

Type of Body Art

Tattoo

OtherOther

Description of Tattoo Location

Artist/Technician *

Jordanne Le Fae

Michaela Erickson

Laura Frego

Jennie Kiebler

Blu Zengaffinen

Erin Hunter

Matte Black

Rachael Lare

Julia Ragalie

OtherOther

Please Take a Photo of Your ID *

Maximum upload size: 268.44MB

MEDICAL HISTORY

Please Select Any Conditions Listed Below that Apply to You

Diabetes

Hemophilia

Skin Disease (psoriasis, eczema, etc.)

Skin Lesions

Skin Sensitivity to Soap or Disinfectant

Epilepsy

Seizures

Fainting

Narcolepsy

Are you allergic to cocoa butter or latex? *

Yes

Do you have any 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 any cardiac valve diseases? *

Yes

Additional Health Information (including details for any "Yes" answers in this section)

How long has it been since you last ate? *

INFORMED CONSENT TO RECEIVE BODY ART

Please read and sign when you are certain you understand the implications of signing.

Read and check off all statements below:

In consideration of receiving BODY ART from the practitioner listed above at Weird Ink Society (together with its employees and other technicians, the "Establishment", I, the below signed, 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.

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

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

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.

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

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

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 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.

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

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

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.

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

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

I agree to pay for the body art procedure performed today.

Please check the box to confirm the following statement: *

I have been fully informed of the risks of body art including but not limited to infection, scarring, and allergic reactions to items associated with body art procedures. Technician will not perform the body art procedure if you fail to complete or sign this form. Further, technician may decline to perform a body art procedure if the client has any identified health conditions. Having been informed of the potential risks associated with this body art procedure, I still wish to proceed with the body art application and I assume any/all risks that may arise from body art.

Client Signature *

Clear

Please have your artist sign below.

Artist Signature *

Clear

Artist, please review Medical History before signing.

If you are human, leave this field blank.