Tattoo Consent Form

Tattoo Consent Form
Client Information
Name*

First NameLast Name
Birth Date*

MonthDayYear
Date
Phone Number*
Format: (000) 000-0000.
Email*
example@example.com
Drivers license number *
Address*

Street Address

Street Address 2

CityState / Province

Postal / Zip Code
Site of Procedure *
Pre-Procedure Questionnaire
YesNo
YesNo
Skin conditions (e.g. Rashes, eczema, infection, psoriasis, freckles, etc.)*
If yes, please identify the condition.
Please tell about your medical history (e.g. DIabetes, Cardiovascular Disease, Epilepsy, Blood-related disease etc.)*
If yes, please identify the condition.
Know Potential risks associated with tattooing; Scarring, localized infections, allergic reactions to pigment. Localized swelling around the site.

I give full consent to the tattooing being carried out by the aforementioned practitioner. I confirm that potential complications, e.g. infection and swelling, for the procedure undertaken, and aftercare instructions have been explained to me. A written aftercare advice sheet containing more detailed information has been given to me and I agree that it is my responsibility to read this and follow the instructions on it, until the site has healed.

I confirm that the above information provided by me for this consent form is correct to the best of my knowledge, that I am over the age of consent for this procedure (i.e. 18 years old for tattoos) and that I a, not currently under the influence of alcohol or drugs.
Client Signature*

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The nature and method of proposed tattoo procedures has been explained to me as having the usual risk inherent in the procedure and the possibly of complications during and follow its performance. I understand that there may be a certain amount of discomfort and pain associated with the procedure and that other possible adverse side effects may include: minor and temporary bleeding, bruising, redness or other discoloration and/or swelling. Fading or loss of procedure may occur due to the nature of fineline tattoos and touch ups may be needed.

By signing below, I specifically acknowledge that I have been advised of the facts and matter set below.
Client Signature*

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Acknowledgment and Waiver

(Check box to acknowledge)
I have informed the practitioner of any and all of my known allergies. I acknowledge that it is not always possible to determine in advance whether I might have an allergic reaction to any of the pigments, dyes, topical or processes used in this procedure; and I agree to accept the risk that such reaction is possible.
I consent to any relevant photographs being taken before, during, and after the procedure, to document the procedure and/or for educational purpose for use of Modern Beauty.
I consent to Modern Beauty using “before & after” photos of my tattoo for marketing purposes to display its capabilities and results.
I acknowledge that complications as a result of tattoo procedures may occur, particularly in the event that the instructions are not followed, and accept full result responsibility for such complications.
I realize that my body is unique and neither Modern Beauty nor The Archery Inc. can predict how my skin will react in results of the procedure.
I understand that I need to take care of the tattoo by following the instructions given to me by the Tattoo Shop.
I understand that I might get an infection if I don't follow the instructions given to me in regards of taking food care of my tattoo.
I acknowledge that the procedure may result in long lasting (Many years) change to my appearance and that no representations have been made to me as to the ability to later change or remove results.
I understand that future skin altering procedures such as laser treatments, plastic surgery, implants, and/or injections may alter and degrade my tattoo , and that I must inform any future service providers that I have had permanent tattoos applied. I understand and accept that such changes are not the fault of Modern Beauty. I further understand that such changes or degradation in my appearance may not be correctable through further tattoo procedures.
I acknowledge that obtaining the tattoo is my choice alone, I consent to the procedure and to its risks, and to any actions or conducts of Modern Beauty reasonably to perform the procedure.
I understand that I will have the opportunity to approve the design and color of the tattoo applied, and responsibility for the same.
I have been given the full opportunity to ask any and all questions which I have about obtaining a tattoo from Modern Beauty and all of my questions have been answered to my full and total satisfaction.
Signed Date*

MonthDayYear
Date
Client Signature*

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Tattoo Consent Form

Client Information

Pre-Procedure Questionnaire

Acknowledgment and Waiver