Consent Form Please fill out the required fields Practitioner * Select your Tattoo Artist performing the procedure Johnny Angel Jose Cruz Jenny Thee Kidd Christian Medina Dreadnot Sly Williams Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Email * Drivers License/ID # * State of Issurance * State your Drivers license/ ID was issued Checkbox * Check any conditions that apply to you or check None if none apply to you Herpes at Procedure Site Diabetes Epilepsy Fainting/Dizziness Cardiac Valve Disease Hemophilia Blood Thinners Pregnant/Nursing T.B. Eczema/Psoriasis Scars/Keloids Latex Allergy Antibiotic Allergy Other (please describe your condition in the next section below) None If you choose Other above, please describe your condition here: Do you have a history of medication use or currently using medication, including being prescribed antibiotics prior to dental or surgical procedures? * By e-signing this form, I confirm the following statements: * Check the boxes below I am at least 18 years of age and am the person on the legal ID presented as proof of identification. I am not under the influence of alcohol and drugs. I understand that tattoo inks, dyes, & pigments have not been approved by the Federal Drug Administration (FDA) and that the health consequences of using these products are unknown. I understand there is a possibility of an allergic reaction to the inks, dyes, & pigments commonly used in tattooing. I understand that if I have any skin treatments, laser hair removal, plastic surgery, or any other skin altering procedures, it may result in adverse change to my tattoo. I understand that there may be variations in my chosen tattoo design and color and that colors on deeper pigmented skin do not appear as bright. I understand that there is a chance I might feel lightheaded, dizzy, and/or faint before, during or after being tattooed and agree to immediately notify the practitioner if any of these events occur. I understand there is a possibility of getting an infection and I have been advised of the signs and symptoms of infection that indicate a need to seek medical attention. I agree to follow all instructions concerning the care of my tattoo and that any touch-ups needed due to my own negligence will be done at my own expense. All questions about the body art procedure have been answered to my satisfaction and I have been given written aftercare for the tattoo I am about to receive. E-sign and date your consent form to submit * I, (First Name/Last Name), have been fully informed of the risk of tattooing and still wish to proceed with the tattoo application and I assume any and all risks that may arise from tattooing. First Name Last Name Date * Today's Date MM DD YYYY Thank you!
