Tattoo Consent Form Tattoo Consent Before we can sit you down in a chair, we just need to do a little record keeping. Lets start with the name of the artist with whom you have a booking. Artist Completing The Tattoo * Select Artist ChuckHeatherIanJamesJessJenniNiscoPhoenixSaraSaylorZaneGuest Artist Is this a scheduled appointment? * Select Type Walk InScheduled Appointment Personal Information First * Last * Phone Email * Drivers License or I.D. # * NO ID = NO TATTOO DOB * Age * Address * Address Address Address City City State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Zip/Postal Zip/Postal Emergency Contact * Emergency Phone * Description of Tattoo * Location of the body the tattoo is being performed on * Medical History Have you been tattooed before? * Yes No Do you have a skin disease or skin lesions? * Yes No Are you Pregnant * Yes No Do you have a heart condition, epilepsy, diabetes, seizure, narcolepsy, or fainting? * Yes No If yes, please explain Are a hemophiliac (bleeder) or on any medications that may cause bleeding or may hinder blood clotting, such as anticoagulants? * Yes No If yes, Please explain Do you have any communicable diseases? (H.I.V., A.I.D.S., HEPITITIS) * Yes No If yes, Please explain Are you under the influence of alcohol or drugs, prescribed or otherwise? * Yes No If yes, Please explain Do you have any adverse reactions to pigments, dyes, disinfectants, or soap? (Medicines or Topical Solutions) * Yes No If yes, Please explain Doctor’s Information Name Phone Number Doctors Address Doctors Address Doctors Address Doctors Address City City State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Zip/Postal Zip/Postal Waiver and Release #1 * To my knowledge, I do not have any mental, medical impairment, or disability which might affect my well-being as a direct or indirect result but my decision to have any tattoo and / or piercing procedure done at this time #2 * I agree to follow all instructions concerning the care of my tattoo and / or piercing while it’s healing. I agreed that any touch up work, due to my negligence, will be done at my own expense. #3 * I understand that tattoos will be permanent alteration to my body and tattoo / piercings may leave scarring. #4 * Being of sound mind and body, I hereby release any and all employees, agents or persons representing Phoenix Tattoo Co. From all responsibilities. I agreed not to sue Phoenix Tattoo Co. Or its heirs or assigns in connection with any and all damages, claims, demands, rights and causes of action of whatever kind of nature based upon injuries or property damages to or death of myself or any other person’s arising from my decisions to have any tattoo and / or piercing related work at this time, whether or not caused by any negligence of Phoenix Tattoo Co. Employees. #5 * I agree for myself, my heirs, assigns and legal representatives to hold harmless from all damages, actions, causes of any decision to have any tattoo and / or piercing work done by Phoenix Tattoo Co. #6 * I swear or affirm and agree that the above information is true and correct. I have been provided with information describing the tattoo and / or piercing procedure to be performed and instructions on aftercare. I have been made aware that if I have any signs or symptoms of infection, such as swelling, pain, redness, fever, unusual discharge or odor to contact my physician. It is also my responsibility to take care of my new tattoo and / or piercing site according to the instructions provided both verbally and in writing. Date * Drivers License or I.D. Upload * Drivers License or I.D. Drivers License or I.D. Maximum upload size: 10MB Birth Certificate (Under Age Clients) Birth Certificate Choose File Maximum upload size: 10MB Customer Signature * Clear Captcha Tattoo Information Needle Lot # Needle Exp. Date Ink Lot # Ink Pigment If you are human, leave this field blank. Submit Consent
