Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Date of birth *

MM

DD

YYYY

Do you have any known allergies or adverse reactions to substances such as nitrile, pigments, dyes, disinfectants, metals, adhesives, or other sensitivities related to body art procedures? *

Yes (please discuss with your artist before proceeding).

No

Do you have a history of epilepsy, seizures, fainting or narcolepsy? *

Yes (please discuss with your artist before proceeding).

No

Are you currently taking any medications or do you have any conditions that may affect blood circulation and/or your ability to fight infection? *

Yes (please discuss with your artist before proceeding).

No

Are you on any medication or have any condition that may affect blood circulation and/or ability to fight infection? *

Yes (please discuss with your artist before proceeding).

No

Are you currently pregnant or breastfeeding? *

Yes (unfortunately, we cannot proceed with the tattoo at this time).

No

Have you eaten within the last 4 hours? *

Yes

No

Do you consent to your artist using photos and/or videos of your tattoo for social media, promotional, and portfolio purposes? *

Yes

No

I affirm that I am over the age of 18 and can legally consent to receiving this tattoo. *

Yes

I confirm that I am consenting to this tattoo of my own free will, without influence from any other person, and without being under the influence of drugs and/or alcohol. *

Yes

I understand that receiving a tattoo is a permanent change to my physical appearance.

Yes

I acknowledge that tattoo removal may not be possible or may result in scarring. *

Yes

I accept all risks and responsibilities associated with the tattoo, including but not limited to infections, blowouts, and reactions during and after the procedure. *

Yes

I take full responsibility for the design/text of the tattoo, from the initial design to the final application, including grammar, punctuation, and spelling. *

Yes

I agree to follow the aftercare instructions provided by the artist, understanding that failure to do so may lead to negative outcomes for which I am responsible. *

Yes

I understand that certain medications and/or medical conditions may interfere with the tattoo and healing process, potentially increasing complications and healing time. *

Yes

I confirm that I am not experiencing symptoms of illness such as cough, shortness of breath, fever, chills, muscle pain, headache, sore throat, or loss of taste or smell. *

Yes

I have read and understood the above statements, and I declare under penalty of perjury that the information provided is accurate.

Yes