Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

Country

(###)

###

####

Date of Birth *

MM

DD

YYYY

Date of Procedure *

MM

DD

YYYY

Type of Identification Provided: *

Driver's License

Passport

Military ID

Tribal ID Card

Permanent Resident Card

MEDICAL HISTORY *

Please select any conditions listed below that apply to you:

Diabetes

Hemophilia

Skin lesions

Seizures

Fainting

Narcolepsy

Epilepsy

Skin sensitivity to soap or disinfectant

Skin disease (psoriasis, eczema, etc.)

Keloid Skin

I understand that a tattoo is considered permanent and may only be removed with a surgical procedure. *

I understand

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

I understand

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

Yes

I am under the age of 18 years old and have the presence of my parent or guardian to receive the body piercing (applicable only to underage body piercing. N/A if not applicable). *

Yes

N/A

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'm not under any influence

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

Yes

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. *

Yes

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. *

Yes

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

I understand

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

I understand

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 am aware

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

I understand

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

Yes

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. *

Yes

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

I understand

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