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CONSENT FORM

Please read the following consent form carefully. The process of your tattoo or piercing may cause complications with existing medical conditions, some of which may result in our practioners refusing treatment. Please answer all questions honestly so that we can provide you with the best service and aftercare.

Name *

First

Last

Date of Birth *

Address *

Email *

Appointment Date

Which practitioner are you getting tattooed/pierced by? *

Do you smoke/vape?

Yes
No

Do you suffer from any heart conditions? *

Yes
No

If you have marked 'Yes' Please let us know in the Notes box at the bottom of this page.

Do you suffer from Epilepsy? *

Yes
No

Do you suffer from Haemophilia or other blood clotting disorders? *

Yes
No

If you have marked 'Yes' Please let us know more information in the Notes box at the bottom of this page.

Do you suffer with Eczema, Psoriasis, Acne, Cellulitis or other skin conditions? *

Yes
No

If you have marked 'Yes' Please let us know more information in the Notes box at the bottom of this page.

Do you suffer with high/low blood pressure? *

Yes
No

If you have marked 'Yes' Please let us know more information about how your blood pressure is treated in the Notes box at the bottom of this page.

Do you suffer from Diabetes? *

Yes
No

If you have marked 'Yes' Please let us know how your diabetes is managed in the Notes box at the bottom of this page.

Do you suffer from any autoimmune diseases such as Hepatitis, HIV or AIDS? *

Yes
No

If you have marked 'Yes' Please let us know more information in the Notes box at the bottom of this page.

Are you currently undergoing any treatment that could adversely affect your immune system e.g cancer treatment? *

Yes
No

If you have marked 'Yes' Please let us know more information in the Notes box at the bottom of this page.

Do you suffer from any known allergic responses e.g latex/nickel/plasters/creams/other? *

Yes
No

If you have marked 'Yes' Please let us know more information in the Notes box at the bottom of this page.

Do you take any regular prescribed medications? (especially blood thinners such as Warfarin, high dose Aspirin, or immuno-suppressants such as steroids) *

Yes
No

If you have marked 'Yes' Please let us know more information in the Notes box at the bottom of this page.

Are you/could you be pregnant? *

Yes
No

If you have marked 'Yes' Please let us know more information in the Notes box at the bottom of this page.

Do you suffer with any other condition that is not listed? *

Yes
No

If you have marked 'Yes' Please let us know more information in as much detail as possible in the Notes box at the bottom of this page.

Are you currently suffering with any symptoms associated with Covid-19? (e.g chesty cough, loss of taste and/or smell, flu-like symptoms) *

Yes
No

If you have marked 'Yes' Please let us know more information in the Notes box at the bottom of this page.

Do you own pets? *

Yes
No

Pet hair can carry oils that are detrimental to the healing process, so knowing this can help us give you the best aftercare information.

Notes

Declaration of Consent *

I declare that I give my full consent to be tattooed/pierced by the previously stated tattoo artist/body piercer and I confirm that the information I have provided in this document is accurate and true.

Declaration of Aftercare *

I am aware that I will need to follow aftercare instructions given to me by my tattoo artist/body piercer

Are you okay with us adding your email address to our Mailing List (and our subsequent artists personal mailing lists)?

Yes

Any further comments or messages?

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