Consent Form

Name *

First Name

Last Name

Phone

(###)

###

####

Birthday

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Who is your artist for the day? *

Shaun

Jack

Dan

Do you have any medical conditions (including skin conditions)?

Yes

No

Do you have a transmissible disease or virus?

Yes

No

I confirm that I am not pregnant

I confirm that I am not under the influence of drugs and alcohol

I understand that this procedure is a permanent change to my skin and body

I allow my tattoo to be photographed and filmed, and be used by both professional artist and tattoo studio in perpetuity

I agree that the studio does not have a way of identifying if I am allergic to the elements or ingredients that will be used for my tattoo

I understand that I need to take care of the tattoo by following proper instructions give to me by my artist

I acknowledge that infection is always possible as a result of the obtaining of a tattoo, particularly in the event that I do not take proper care of my tattoo. I agree that any touch-up work needed, due to my own negligence, will be done at my own expense

I confirm that all of the information I have provided is accurate and true

Signed Date

MM

DD

YYYY

Signed Name

First Name

Last Name