1. Name of Tattooist: *

1. Name of Client: *

1. Contact Number:

1. Address: *

1. Age of Client: *

1. DOB of Client: *

1. Client's Email

Please read the following information carefully and if any of these conditions apply to you please discuss them with your tattooist prior to having your tattoo

Individual Consent I declare that I give my full consent to the tattooing being carried out by the aforementioned practitioner. 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 am not currently under the influence of alcohol or drugs. Please attach an image of your ID here:

1. Proof Of ID:

1. I knowingly and willingly consent to having tattoo/Body Piercing service(s) with the potential risk of exposure to COVID19 and crona virus strains. By selecting “YES” i understand and accept this statement. YesNo

Do you suffer from any of the following conditions ?

1. Eczema, Psoriasis, Acne, Cellulitis, Psoriasis Or Other Skin Conditions - More prone to skin infections. YesNo

1. Heart Disorders - More prone to serious heart complications from any blood infections. YesNo

1. High/Low Blood Pressure - Can cause light headedness YesNo

1. Haemophilia And Other Bleeding Disorders - may result in poor clotting/healing YesNo

1. Epilepsy Or Other Forms Of Seizures - Medication may cause side effects and may result in fitting during treatment. YesNo

1. Diabetes (Type 1 Or Type 2) - Can reduce healing properties of the skin resulting in infection YesNo

1. Hepatitis - May pose a risk for operator YesNo

1. Autoimmune Disease Or Treatment Causing It i.e Cancer Treatment - More prone to serious infection, HIV a risk for operator. YesNo

1. Allergies Especially Latex Or Nickel Allergy - May result in serious skin reactions present in products, i.e ink YesNo

1. Pregnant - Immune response affected by pregnancy and any infection may affect the unborn child. YesNo

1. Nursing Mother - Risk of infection can be a risk to the baby YesNo

1. Medication - side effects may affect healing and recovery from treatment. YesNo

1. If you have any other medical condition/important imformation not listed above please give details below: