CONSENT FORM

Name *

First Name

Last Name

MEDICAL CONDITONS

SELECT THE BOXES OF ANY CONDITIONS THAT APPLY YOU:

ECZEMA, PSORIASIS, ACNE, CELLULITIS OR OTHER SKIN CONDITION - more prone to skin infections

HEART DISEASE - more prone to heart complications from blood infections

HIGH/LOW BLOOD PRESSURE - can cause feeling light headed

HAEMOPHILIA OR OTHER BLEEDING DISORDERS - may result in poorclotting/healing

EPILEPSY/SEIZURES - medication can cause side effects and may result in fitting

DIABETES - can reduce healing properties of the skin resulting in infection

HEPATITIS A B OR C - poses a risk to the tattooist

HIV - poses a risk to the tattooist

CANCER/CANCER TREATMENTS- having a reduced autoimmune system risks being more prone to serious infection

ALLERGIES - may result in reaction to ink/ other products

PREGNANT - any infection may affect unborn child

BREAST FEEDING - possible infection is a risk to the baby

ON MEDICATION - side effects may affect healing and recovery from treatment

BY TICKING THE BOXES BELOW I AGREE:

I AM OVER THE AGE OF 18 (ID required)

I HAVE EATEN IN THE LAST 2 HOURS

I HAVE NOT CONSUMED ALCOHOL OR DRUGS IN THE LAST 24HRS

Date

MM

DD

YYYY

I ACKNOWLEDGE THAT I GIVE MY FULL CONSENT TO THE TATTOO PROCEDURE. AS THE PROCEDURE INVOLVES MINOR BREAKAGE OF THE SKIN WITH A NEEDLE, I UNDERSTAND THE HEALTH RISKS AND HAVE COMPLETED THIS FORM TRUTHFULLY AND TO THE BEST OF MY KNOWLEDGE *