Name *

First Name

Last Name

Birthdate *

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Are you 18 years of age or older? *

Yes

No

Are you pregnant or nursing? *

Yes

No

Are you under the influence of drugs or alcohol? *

Yes

No

Are you getting a tattoo under your own free will? *

Yes

No

Are you allergic to latex? *

Yes

No

Are you allergic to or have any sensitivity to adhesives such as bandages? *

Yes

No

Are you allergic to or have any sensitivity to soaps or disinfectants? *

Yes

No

Are you taking any antibiotics or anti-coagulant medication? *

Yes

No

Have you had any alcohol in the last 24 hours? *

Yes

No

Please indicate if you have any of the following conditions:

Hemophilia

Diabetes

Heart condition

High blood pressure

Eczema

Psoriasis

Autoimmune disease

I understand that it is my responsibility to take proper care of my tattoo at the artists instruction. I acknowledge that infection is always possible as a result of getting a tattoo when not care for properly. I acknowledge that any touch up work that is required due to my own negligence will be done at my own expense

Yes

No

I understand that it is my responsibility to proofread any lettering or dates for accuracy and that once I agree to the placement of my stencil that any artwork errors are my responsibility.

Yes

No