Date Today

Full Name *

Date of birth *

Phone *

Email *

Address

Street Address

City

State

Country

Postal Code

Are you currently or have you ever used medications that contain a controlled substance?

Have you ever been diagnosed by a medical doctor as to having contracted communicable disease such as Human Immunodeficiency Virus (HIV), Hepatitis B Virus (HBV)and/or other blood borne pathogens? If so, when?

Have you ever been diagnosed by a medical doctor as having allergies?

Have you recently been diagnosed by a medical doctor as to having a disease that could affect the healing process, including diabetes?

Are you currently under the influence of any illegal substances ?

Are you currently under the influence of an alcoholic beverage ?

Have you been diagnosed with jaundice within the past twelve months ?

Are you currently using any medications that contain blood thinners ?

Are you currently using any medications that weaken the immune system that fights infections ?

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I acknowledge that I am aware certain medical conditions and treatments and/or medications used to treat those medical conditions may be adversely impacted by the procedure(s) of tattooing and/or body piercing and/or branding. Such medical conditions include but are not limited to, impaired kidney and/or liver function, diabetes, jaundice, medication containing blood thinners and medicationsT & C*I acknowledge that I am aware certain medical conditions and treatments and/or medications used to treat those medical conditions may be adversely impacted by the procedure(s) of tattooing and/or body piercing and/or branding. Such medical conditions include but are not limited to, impaired kidney and/or liver function, diabetes, jaundice, medication containing blood thinners and medications that weaken the immune system.I further acknowledge that the tattoo and/or brand should be considered permanent; that said tattoo and/or brand can only be removed with a surgical procedure; and that any effective removal may leave permanent scarring and disfigurement.I have read this form and confirm that all the information I have given is correct. I understand that this is a consent form and I agree to be legally bound by it. that weaken the immune system.

I further acknowledge that the tattoo and/or brand should be considered permanent; that said tattoo and/or brand can only be removed with a surgical procedure; and that any effective removal may leave permanent scarring and disfigurement.

I have read this form and confirm that all the information I have given is correct. I understand that this is a consent form and I agree to be legally bound by it.

Media Release Agreement
By signing this agreement, you grant the artist and studio full permission to photograph and/or film your tattoo session and the completed tattoo. These images may be used for marketing, social media, educational, or promotional purposes, including but not limited to Instagram, website content, and advertisements. You acknowledge that no compensation is provided for this use and that all media remains the intellectual property of the artist and studio.