Full Legal Name:
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Must match your Government Issued Photo ID as required by public health. Please bring your ID to your appointment.
First Name
Last Name
Date of Birth:
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You must be 18 years of age or older on the date of your tattoo appointment.
MM
DD
YYYY
Phone Number:
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(###)
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Email Address:
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Home Address:
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Emergency Contact Info:
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Please include their full name, relationship to you and a contact number. If you do not want us to contact someone you know you can write 911.
First Name
Last Name
Relationship to you:
Phone Number:
(###)
###
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Is this your first tattoo?
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Are you pregnant or nursing?
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Are you prone to fainting, dizziness or light headedness?
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Are you currently under the influence of any drugs or alcohol?
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Do you have any heart conditions? I.e. High Blood Pressure, Low Blood Pressure, Angina or other.
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Do you experience epilepsy? If yes, please include if it is managed and stable.
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Do you have diabetes? If yes, please include Type 1 or 2.
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Have you ever experienced any of the following issues with your skin?
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Do you have any blood disorders, diseases or viruses?
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Are you currently taking any medications?
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Do you have any other health concerns your artist should be aware of?
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I understand the process of getting tattooed and feel comfortable that I have asked my artist any questions I may have. I am aware that feeling dizzy or fainting during the tattoo procedure is not uncommon and I consent for my artist, or other staff present, to assist me if I lose consciousness with no liability to the staff or persons involved.
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I acknowledge it is not reasonably possible for the representatives and employees of this tattoo shop to determine whether I might have an allergic reaction to the pigments or processes used in my tattoo, and I agree to accept the risk that such a reaction is possible.
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I understand that the tattoo studio is an inclusive environment which should be treated with respect. Any behaviour deemed remotely inappropriate, towards staff or clients will not be tolerated. Our team reserves the right to terminate your appointment at any time if we have a strong belief that this behavior is occurring. This includes cancelling future appointments.
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I understand that tattoos are a permanent procedure, and if I change my mind that removal will not be in any way paid for or facilitated by the studio. To the best of my knowledge I have no medical or mental impairments which could directly or indirectly influence my decision making. I am freely making the decision to get this tattoo, with no feeling of coercion by outside parties or groups.
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I realize that variations in color and design may exist between any tattoo as selected by me and as ultimately applied to my body, including changes in healed colour, line thickness, natural fading etc.
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If you wish to provide clarification, ask me a question or have any requests for accommodations please write them here:
I confirm that all the statements above are true to the best of my knowledge and that I am over the legal age of consent for this procedure that I am agreeing to.
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Needle Lot Numbers